Quiz 16.docx

**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 pt’s data & suggest appropriate medical/nursing interventions. Can also trigger prompts/alerts to user. Requires human u...

**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 pt’s data & suggest appropriate medical/nursing interventions. Can also trigger prompts/alerts to user. Requires human user input. Decreases pt safety risk & increases positive pt outcomes (alerts for abnormal vs, lab results, med contraindication, etc.) The right components of a CDS include a trigger, such as med order; input data, such as lab values; intervention info, such as other options provided; & action step, such as action selected by the Dr.  **Electronic Health Record (EHR) – Database of individual’s healthcare data during healthcare encounters. It’s comprised of any pt data stored in electronic form. Electronic form/ database of a pt’s past medical history, medical test, medications, images, etc. stored in electronic form. Enables many functions needed to create & maintain EHRs. You will know if the EHR is successful if the customer’s needs were met. **Electronic Medical Record (EMR) – Legal record created in hospitals & ambulatory settings of single encounter/visit that is source of data for EHR. Brings together diagnostic & treatment info for an individual in specific healthcare setting. ** Usually found in a physician’s office. Electronic Medical Record Adoption Model (EMRAM) – Measures clinical outcomes, pt engagement, & clinical use of EMR technology to strengthen organizational performance & health outcomes across pt populations. Basically evaluates Health Information Systems. Ergonomics – Scientific study of work & space, including details that impact productivity & health. **Evidenced Based Practice (EBP) – Current, best evidence for pt care. Improves consistency & quality of pt outcomes. Foundation of clinical practice & guides clinicians. Found in standing orders (ex. Sepsis protocol). Expert System – A type of CDS/DDS but does NOT need human intervention, uses artificial intelligence (ex. Insulin pump). **Fishbone – A tool for analyzing the organizational processes & its effectiveness. Helps team members visually diagram a problem or condition’s root causes, allowing them to truly diagnose the problem rather than focusing on symptoms. Five Rights to Clinical Decision Support: Right Information, Right Person, Right Intervention, Right time in the workflow, & where. **Health Information Exchange (HIE) - Electronic sharing of pt information between healthcare providers according to nationally recognized standards, allows insurance companies & providers to share data, must be secure & maintain integrity. Works by improving speed, quality, safety, & cost of pt care. Query-based exchange often used for unplanned events. (ex. ER) It allows providers to find & request info on a pt from other providers. Directed exchange is used to support coordinated care & allows the ability to send & receive secure information electronically between care providers. Consumer-mediated exchange allows the ability for pts to review, manage, & control the use of their health information among providers. Allows insurance companies & providers to share data (or across delivery settings). Nationally recognized standards/ Federal legislation demands for safer, more efficient healthcare. Increases efficiency & quality care. All states have implemented Health Information Exchange. Must be secure & maintain integrity. **Health Information Technology (HIT) – Various systems & technology used to record, monitor, & deliver pt care, as well as perform managerial & organizational functions. HIT is used to support systems that collect data needed for pt care, population health management, & for the sharing of this information within a secure system. Large datasets resulting from Meaningful Use (MU) & other incentives will provide increased evidence to support HIT policy decisions that weigh national, as well as global implications. **Health Information Technology for Economic & Clinical Health Act (HITECH Act) – The HITECH Act provides funds & incentives to increase EHRs by providers, improve policy decisions, & allocate services, funded workforce training, & new technology research. HITECH strongly recommends increasing meaningful use of HIT to decrease overall healthcare cost & to improve population health. **Health Insurance Portability & 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 & should never be left unattended. Email & instant messaging may carry PHI that can be intercepted. Fines prior to 2/18/09 are $100/violation w/ a max of $25000 yearly. If after 2009, fine can be $100-50000+/violation, w/ a max of $1.5 million yearly. Criminal penalty fines can be up to $50000 & 1-year in jail. **Health Level 7 (HL7) – A standard/framework for the exchange of data (PHI) between information systems w/ extensive set of rules that applies to all data that is exchanged, shared, integrated, or retrieved. Refers to both organization & its standards to exchange data. Specifies how the data is coded. **Health Literacy - capacity of an individual to express their needs & preferences & to respond to the need for info about services provided for them. Low health literacy highly impacted by culture, ethnicity, race, environment, & social class. Health literacy involves teaching pts enough info about their illnesses & about how the health system works so they can appropriately management their health. Most common challenge in advancing health literacy is assuming pts understand the medical terminology that healthcare pros are comfortable with. Health literacy is not restricted to knowing how to interact w/ the internet for their health information.  **Informatics – INTERDISCIPLINARY FIELD. It is the science & art of turning data into information. Combines computer/decision/information/management/cognitive sciences & organizational theory. COGNITIVE science, & organizational theory. Broad scope encompasses natural language processing, data mining (looking for hidden patterns & exceptions in large groups), research, decision support, & genomics. Informatics Innovator – Expected to be educationally prepared to conduct informatics research, generate informatics theory, & have advanced understanding & skills in information management & computer technology. Informatics Specialist – A RN w/ advanced skills specific to health information management & computer technology w/ expertise in systems development life cycles. Information – Data that has been interpreted. Information Literacy – Ability to recognize when information is needed as well as the skills to find, evaluate, & use needed information effectively. Information literacy is the knowledge & ability to locate, organize, use, communicate, & interpret print & electronic sources of information.  **Information Security – Information has value & requires protection. Confidentiality – Relationship has been established where private information is shared but not disclosed unless the pt givens permission. **Phishing – Deceptive method used to steal sensitive information. In phase 1, the recipient typically receives a phish, or e-mail. Phase 2 involves the victim following through on what they are asked to do, such as completing a form. Once the recipient completes the information, the hackers now have information that they can use for nefarious purposes. Privacy – The right to control access & disclosure or nondisclosure of information pertaining to oneself & to control the circumstances, timing, & extent to which information may be disclosed. **Integration - Process by which 2 different information systems can exchange data in a way that is seamless to the end-user. **Interface - Computer program that tells 2 different systems how to exchange data. **International Classification of Diseases-10th Revision (ICD-10) - Is the international standard diagnostic classification for health-management purposes, & clinical use. The ICD diagnoses are used to classify mortality & morbidity data from input & output records. Also used for reimbursement. **Interoperability - The ability of 2 entities, human or machine, to exchange & predictably use data or information while retaining the original meaning of the data. A RN informaticist can increase interoperability by promoting standardized vocabulary & coding. This reduces errors, increases revenue, & increases communication. Interoperability allows timely & seamless portability of information & optimizes the health of individuals & populations globally through this seamless exchange. *** Using an interoperable system, you can expect a reduction in errors, increase in revenue, & increased communication*** **Joint Commission – ACCREDITATION. Key standards of information management: protect & aggregate data, uniform definitions/language, teach information management (training), & address disaster & preparedness. Knowledge – Synthesizing information from different sources to produce a concept of idea.