RN Engage 2.0 - Informatics

Technology in Nursing Education and Practice

• Informatics utilizes information and technology for communication, knowledge management, error mitigation, and decision support.
• Nursing informatics integrates technology with nursing knowledge and clinical decision-making skills.
• Florence Nightingale used informatics in the 1850s to analyze data and improve sanitation.
• The American Nurses Association formally defined nursing informatics as a specialty in 1992, allowing for nurse informatician certification.

Simulation in Nursing Education

• Simulation enhances student engagement and prepares nurses for complex healthcare settings.
• It mimics real-life situations for practicing, assessing, and acquiring knowledge of systems or actions.
• Clinical decision-making involves assessing a client, identifying priority concerns, and implementing evidence-based interventions.
• Simulation improves student performance, motivation, and competence, fostering a student-centered learning environment and active engagement.
• Simulation scenarios allow students to practice leadership, communication, and electronic medical record documentation skills.
• Decreasing clinical sites and faculty availability increases the importance of simulation.
• Simulation is an evidence-based learning technology which allows a safe environment for students to practice skills.

Clinical Information Systems

• Clinical information systems allow instant retrieval of client information.
• They are utilized by nurses, providers, and other members of the interprofessional team at the clinical point of care site.
• Information technology creates and stores information and includes electronic health records.
• Barcode scanning, documentation, medication administration, and arm band scanning are examples of clinical information systems.
• Electronic health records provide real-time computerized access to a client’s medical history, diagnoses, allergies, and test results.
• A clinical information system can expedite decision-making by providing accurate and reliable client information.
• It efficiently processes client protected health information (PHI) and complex medical information.
• It decreases health care workers’ response time to clients, allows for more rapid diagnoses and comprehensive treatment plans that enhance client satisfaction.

Clinical Pathways

• Clinical pathways standardize healthcare delivery for specific client groups using evidence-based guidelines.
• They're decision support tools outlining steps for predetermined clinical problems and anticipated clinical courses.
• Clinical pathways improve client outcomes, care effectiveness, and efficiency while managing expenses and maintaining quality care.
• High-value client care is safe, effective, efficient, unbiased, and client-centered.
• Clinical pathways management systems are more effective at decreasing length of stay, major complications, and total costs per client compared to paper-based systems.
• Software-based clinical pathways facilitate the monitoring of protocols and the efficiency of the nursing unit.
• Nurses must accept the use of clinical pathways in providing client care for the clinical pathways management system to be effective.

HIPAA and Confidentiality

• HIPAA is a federal law enacted in 1996 to protect clients’ medical health information accessed or shared electronically.
• The Privacy Rule defines standards for using and disclosing protected health information (PHI).
• The Security Rule establishes safeguards for electronic PHI.
• The Breach Notification Rule mandates notifying clients of breaches of their unsecured PHI.
• PHI includes any information held by a covered entity that can be linked to an individual.
• Unique client identifiers must be coded to protect client privacy.
• Clients have rights over their PHI, including obtaining copies and requesting corrections.
• HIPAA training is an annual requirement for healthcare providers.
• Covered entities must have a HIPAA Compliance Officer or divide duties between a Privacy Officer and a Security Officer.
• The Security Rule addresses the use and disclosure of electronic PHI due to increased use of personal technology. Safeguards that decrease unauthorized disclosure include administrative, technological, and physical controls.
• Breaches of PHI must be reported to the Secretary of Health and Human Services and the affected individual, typically via mail, within 60 days of discovery.

HIPAA Enforcement Rule

• The HIPAA Enforcement Rule oversees compliance, investigations, financial penalties, and violation procedures.
• The Office for Civil Rights (OCR) ensures adherence to Privacy and Security Rules.
• The OCR investigates complaints, determines compliance, and provides education.
• Breaching Privacy and Security Rules leads to OCR attempting resolution through voluntary compliance or corrective action.
• The OCR can impose civil money penalties for noncompliance or partner with the Department of Justice for criminal violations, which include monetary and/or imprisonment penalties.
• Access to medical records is restricted to those needing the information for direct or indirect care.
• Nurses must be careful not to disclose an adolescent client’s protected health information to their parents.
• Sharing client information is legally mandated in some cases such as collecting data about communicable disease for statistical tracking, protecting society from outbreaks of communicable disease, reporting harm caused by a violent act, and assisting law enforcement in solving a crime.
• Breaching client privacy can occur on social media or via personal cell phones.

Telehealth

• Telehealth utilizes telecommunication technologies for client-to-provider communication, assessment, diagnosis, treatment, and disease prevention.
• It eliminates travel, combats the nursing shortage, and addresses growing care demands.
• Telehealth competencies include clinical experience, communication skills, clinical knowledge, legal and ethical awareness, and a supportive attitude.

Use of Personal Devices (Smartphones)

• Healthcare providers are increasingly using smartphone devices to access clinical information and contribute to clinical decision-making
• Sharing client-related information on personal devices can risk prohibited disclosure of PHI. Entering client information into downloadable apps requires understanding data storage, access, and ownership.

Electronic Health Record (EHR)

• The electronic health record (EHR) is a major repository for client information.
• The main driver behind the need for EHR is client safety, followed by efficiency and medical record keeping.
• Proficiency in utilizing and managing EHRs within clinical information systems is needed.
• Meaningful use of EHR technology is needed to maximize efficiency and client safety.
• Certified EHR technology guarantees the EHR system can meet meaningful use criteria, is secure, and can share information with other systems.

Medication Administration

• The EHR has had a tremendous impact on medication administration.
• The Joint Commission (TJC) recognizes the impact of accurate med administration and supports medication reconciliation in the ambulatory care setting
• Medication reconciliation confirms and documents all of the client’s current medications when the client is admitted to the health care institution.
• TJC’s National Patient Safety Goals include improving medication safety by reviewing medications at each clinical encounter.
• ADE is a medication injury caused by a medical intervention.
• Medication errors are preventable errors that can harm a client. Medication errors are among the most common medical errors in all health care settings.
• The medication administration process involves multiple health professionals and health consumers within the four phases of the administration process where errors are likely to occur: ordering, transcribing, dispensing, and administration.
• Barcode medication administration reduces preventable errors, mitigates human errors, and automates the rights of medication administration.

Documentation

• Documentation takes up approximately 40% of health care employee time.
• Key components include charting vital signs, assessments, medication administration, completed treatments, and procedures.
• While electronic documentation enables quick and easy creation and storage of client information, health care workers report struggling to balance documentation and client care tasks.
• Nursing documentation provides evidence of care and is a professional and legal necessity. Inaccurate or incomplete documentation can influence continuity and quality of client care.
• Documentation improvement needs to meet legal requirements, decrease paperwork, and comply with professional standards.
• Point of care barcode scanning and immediate documentation uploads have a significant positive impact on client safety and health care quality.

Electronic Monitoring Devices

• Remote patient monitoring (RPM) is a form of telehealth medicine that assists in the tracking of client information and facilitates the rapid transfer of information to the health care provider.
• RPM assists with the use of mobile medical devices, sensors, and technology to collect client data and transmit the data to health care providers.
• Typical monitored data: heart rhythm, vital signs, blood oxygen saturation, and blood glucose level, gait and activity, and assessing sleep patterns.
• Clients are better able to participate in their health care.
• Many RPM devices permit the client to produce patient-generated health data (PGHD), data that is generated, documented, or collected by the client or caregiver to maintain their health that includes client health history, bodily measurements, symptoms, and individual behavioral factors.

Health Literacy

• Personal health literacy is the extent to which an individual can obtain, process, and comprehend basic health information.
• Organizational health literacy is the extent to which organizations equitably assist individuals with understanding, finding, and using information and services to make informed health-related decisions for themselves and others.
• Digital health literacy affects client outcomes. Lower health literacy, lower digital literacy, poor self-care, and increased mortality have substantial evidence supporting the association between the terms.
• Low health and digital literacy affect an individual’s health status, pose a significant healthcare access barrier, and increase health inequities.
• Clients with lower health literacy levels are also more likely to wait to seek medical care until considerably ill. These factors are associated with higher costs and poor health outcomes.
• Nurses can improve client health literacy through strategies such as speaking slowly, using simple language, using the teach-back method, encouraging questions, and showing examples.
• A workforce with a low health literacy level can and will produce an organizational culture of health illiteracy, leading to significant negative impacts on client outcomes.
• Information management technology optimizes client safety by reducing human errors, facilitating care coordination, improving practice efficiencies, and improving practice efficiencies that lead to clinical outcomes.

Explore technology and simulation in nursing education. Learn the role of informatics, its historical roots with Florence Nightingale. Discover how simulation enhances engagement, prepares nurses for healthcare settings, and improves clinical decision-making skills.