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Mutlidisciplinary Team Terminology

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(SNOMED-CT) Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms- clinical terms covering nurisng, medicine, & allied health

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Standardized Terminology Supports

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Data Mining

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PHR - Private Health Record

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Lifetime health record, supplied by ind., healthcare providers, pharmacies, therapist, lab test, - Controlled by the consumer,

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E-Sign

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Same legal status as a hand written signature

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MIPPA - Medicare Improvement for Patients & Providers Act provides

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financial incentive for e-prescribing to providers

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HIPPA provides

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legal protection for personal health info, set standards for elect. data interchange of claims data, named specific code sets for use in Medicare related transactions, & Privacy

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ARRA provides

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provide funds for adoption of technology & provides the right for every individual to receive and electronic copy of EHR

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HITECH provides

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strengthened HIPPA security & privacy protection, & provides financial incentive for the user of EHR

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EMR -electronic medical record provides

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Legal record often restricted to a Single episode of care , building block of EHR,

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EHR- Electronic Health Record is

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Longitudinal record that includes client data, demographics, clinician notes, medications, diagnostics. - Major driver for US Adoption are "Meaningful Use" financial incentives from HITECH part of ARRA

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Affordable Care Act provides

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guarantee access to healthcare, encourage PCP,

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Data is

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collection of #, characters, or facts (body weight- 128lb), little meaning alone

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Information is

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Collection of data examined for patterns or structure that can be interpreted. ex notes prior BP and informs doc

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Knowledge is

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Synthesis of info from several sources to produce a single concept or idea, ex read a journal about BP

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Computer Technology is

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collection of data for analysis, which can be used to justify the efficacy of particular interventions & improve quality of care

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HIS HEalthcare Information System is

answer

Administrative System + Clinical Information System, Clinical Systems include: order entry, radiology, pharmacy, physician management system Adm system : non clinical, demographics, scheduling, risk mgmt, decision support,

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Administrative System includes these functions

answer

Managing nonclinical, client-related information (demographics, codes for procedures, & Insurance

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Hippa - Compliant Codes inlcude

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(ICD) International Classification of Disease, Common Procedural Terms, (ABC) Alternative Billing Codes,

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ANA recognizes these terminologies

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(CCC) Clinical Care Classification, (ICNP) International Classification of Nursing Practice, NANDA, NIC, NOC, the Omaha System, (PNDS) Perioperative Nursing Data Set

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Teleconferencing is

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use of computers, audio, & video equip. and high-grade dedicated telephone line, cable/sat connections to provide interactive communication between 2+ ppl at 2+ sites

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Elearning provides

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electronic media to present instruction, it allows users to skip information they already know

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Distance Education is

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the use of print, audio, video, computer, or teleconference capability to connect faculty & students; Can take place in real time or on a delayed basis

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Web Based Instruction is

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the attributes & resources of the internet to deliver & support education

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Telehealth is

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use of telecommunication technologies & computers to provide healthcare info & services to clients at another location - consumers are chronically ill, isolated, assisted living families - decrease er visits, decrease LOS, decrease Admissions, increased productivity for clinical

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Telenursing is

answer

telecommunications & computer technology for the delivery of nursing care & services to clients at other sites

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Issues with telehealth & telenursing are

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lack of reimbursement, infrastructure, plug-play standard, license & liability issues, & concerns r/t to client privacy & confidentiality

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EBP- Evidence Based Practice is

answer

the use of research & evidence to inform clinical practice, an approach to provide care that integrates nursing experience & intuition with valid and current clinical research to achieve the best patient outcomes

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EBP provides

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standardized best practices, reduce time that the nurse spends gathering & assessing data, provide care w/ clinical research

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EBP contributes

answer

increased job satisfaction, improved quality of care

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how a nurse uses data

answer

1. accessing information 2. collecting data 3. Inputting Data 4. analyzing data

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quantitative research

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concerned with objectivity, tight control over situations, define relationships between variables, seek correlation between data, ex. tries to discover how an intervention has impacted subjects IN DEPTH, tangible relations between variables,

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qualitative research

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concerned w/ finding out more about the human experience, accomplished thru interviews & over a long period of time, ex. how an intervention could impact an entire population, content analysis, computers can code responses to questionnaires which then can be inputted in the informatics sys for analysis,

question

types of patient information are

answer

1. standard 2. general 3. targeted 4. personalized 5. tailored

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Standard patient information is

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describes procedures that all patients will encounter, ex temperature or weight

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General patient information is

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ask consumers to follow a PREVENTIVE course of treatment that applies to everyone ex yearly physical

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Targeted patient information is

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geared toward ppl who are a SUBSET of the general population ex men >40 prostate exam

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Personalized information is

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gives info about a SPECIFIC condition the consumer has been diagnosed with ex. DMII

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Tailored Information is

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information that focuses Specifically on Ind Based on Specific Conditions , it is typically gleaned from EHR or EMR

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Telemedicine

answer

improve pt outcomes by permitting pts to remain at home, allows pts to communicate w/ provider about blood glucose test or video conference w/ them directly to develop pt specific education opportunities, directed by doctors

question

TIGER means

answer

Technology Informatics Guiding Education Reform

question

ARRA means

answer

American Recovery & Reinvestment Act

question

HITECH

answer

Health Information Technology for Economic & Clinical HEalth

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CPOE

answer

Computerized Physician order entry - needs downtime procedure or policy prior to implementation -

question

DSS

answer

Decision Support Software

question

Info Life Cycle is

answer

1. Needs assessment 2. System selection 3. Implementation 4. Maintence

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Input devices

answer

enter info into the computer such as keyboard, touchscreen, mouse, microphone

question

2nd storage examples

answer

hard disk, usb, dvd

question

out put devices

answer

use to see info such as computer screen, printer, projector, speakers

question

Software

answer

interprets data by binary code, tells the computer what to do at a given moment,

question

operating system

answer

tells how to move, share, and treat files. It also provides a user interface that enables the user to enter info, ex windows

question

application

answer

to perform a certain function; designed to document pt & provider activity ex physician orders

question

network

answer

connect mult computers in different locations

question

LAN

answer

connect a few computers to the server, over large area ex docs place orders remotely at home

question

IntrAnet and extranet

answer

IntrAnet- private networks that can not be accessed outside the organization Extranet- network outside the company that enables customers & suppliers access to the services

question

System Check

answer

help guide thru data collection process, ex. patient allergies to prevent conflict

question

EDI Electronic data interchange

answer

permits mult systems to acquire & share data

question

Nursing Information System

answer

standardized nursing language (SNL), 2 main approaches, 1. Nurisng Process Approach & Critical Pathway- mult discp. teams thru out, physicians orders are present for the multdisc team to observe & follow, allows the the multdisc. team to update the plan of care when variances in the pts condition are noted 2. Protocol Approach- streamline doc of assessment, med info, discharge info, education

question

Firewall

answer

between hardware & software

question

interfacing types

answer

1. point to point - enables to sys to communicate 2. Interface

question

PACS

answer

allows digital manipulation

question

Store & Forward

answer

Part of telehealth, ex xray from clinic sent to hospital

question

clincal codes

answer

designate concepts to facilitate development of EBP

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clinical term

answer

enables the capture of data for patient care documentation

question

Clinical Decision Support System

answer

designed to support health care providers in making decisions about the delivery & mgmt of patient care

question

Consultant

answer

expert advice, opinions, & recommendations

question

4 concepts of nursing informatics

answer

1. data 2. information 3. knowledge 4. wisdom

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Decision Support

answer

recommendations for interventions based on computerized care protocols. ex additional screening, medication interactions, drug dosages

question

Informatics Innovator

answer

process of making enhancements or improvements, creative,

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Informatics Nurse

answer

RN w/ an interest or experiece working in an informatics field

question

Novice

answer

beginner w/ no experience with the situations in which they are expected to perform a task - taught rules to guide actions

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3 sciences of informatics

answer

1. nursing science 2. information science 3. computer science

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Clinical Decision Support System Examples

answer

reminders, alerts, drug checking, guidelines, protocols, image recognition, allergy to drug

question

CPU

answer

consist of computer chip that processes all the computers functions & uses "brain"

question

Data integrity

answer

means that whenever the data are accessed by a user, the data are as complete as when entered or created

question

Information Mgmt

answer

to ensure that the right info. is available to the people at the right time; information is managed properly,

question

Knowledge Mgmt

answer

system that enables organizations to learn from their staff to improve performance, help accumulate & store the collective knowledge

question

Experienced Nurse

answer

expected to more fully integrate informatics throughout the course of practice, not just for basic data entry & retrieval

question

Informatics Nurse

answer

advance knowledge & profienciency in the use of IT as it applies to nursing practice

question

Internet Security Measures

answer

1. Firewall- prevent unwanted access to the sys & its information 2. Limit web page access 3. Server Security- information is stored should not be able to access other systems if attacked 4, Update Security Software

question

Considerations for New Informatics System

answer

1. Technical Specifications - How much downtime for maintenance 2. Response Time- time it takes the sys to process a request 3. Architecture-structure of the sys, open system to communicate together 4. Connectivity-able to interface with the sys in mult ways 5. Testing- tested in different place than it is being used, no sys maintenance can be done w/ little inconvience 6. Compatibility- w/ other systems,

question

Interfacing 2 Types

answer

1. Point to Point- enables 2 sys to communicate, expensive, has to have completely customized program 2. Interface Engine -interfacing across several different sys

question

Smart Technology

answer

links, syncs, & compiles disparate bits of info from different sys into a coherent one stop, real time documentation, provides reminders,

question

Stages of EMR adoption

answer

0- organization has not installed all 3 key ancillary department sys (lab, pharm, & radiology) 1- all 3 key ancillary are installed 2- CDR-clinical data repository provides physician access for reviewing orders & results, Possibly HIE capable 3- Nursing/Clinical Documentation, eMAR, first level of clinical decision support is implemented 4-CPOE implemented 5- Closed loop med administration w/ Bar codes is implemented, 5 rights of medication adm 6. Full Physician Documentation , Full radiology PACS 7-No more paper charts,

question

P4P

answer

Pay for Performance is an outgrowth of Affordable Health Care Act, reward providers when pts have good outcomes

question

Single Risk Pool

answer

prevent insurers from using insurance pools with markets to get around market reforms & charge ppl w/ greater health problems higher premiums by increasing their premiums at higher rates

question

Catastrophic

answer

lower premiums, protect against high out of pocket costs, and cover recommended preventative services

question

Needs to be integrated

answer

ICD-9, G-Codes, ICD-10, CPT, HCSPC

question

Does not need to be integrated

answer

C-3P0, RUGs

question

Telehealth Options

answer

1. Store & Forward- items are transferred to experts who read and interpret information and send back results 2. Real Time- interactive conferencing

question

Nursing Informatics Definition

answer

integration of nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom into nursing practice

question

Computer Literacy vs Information Literacy

answer

Computer Lit- a familiarity with the use of personal computers Information Lit- Ability to recognize when information is needed as as the skills to find, evaluate, and use information

question

Computer System consist of

answer

hardware, software, data, procedures, and users

question

Computer Hardware consist of

answer

input device, the CPU, secondary storage, and output device

question

Network

answer

a combination of hardware and software that allows communication and electronic transfer of information between computers

question

Example of Operating System

answer

Windows Xp

question

Example of application System

answer

Microsoft Word

question

Bit

answer

Smallest unit of data

question

WWW

answer

an information service that provides access to Internet resources by content instead of file name

question

Services of the internet include

answer

file transfer, email, instant messaging

question

Web 2.0

answer

online tool that permits collaboration and sharing online, such as facebook, twitter; Provides education- wikis, web logs, virtual worlds, facebook

question

HIS

answer

group of systems used within a hospital that support and enhance client care

question

CIS-

answer

used to access client data that are used to plan, implement, and evaluate care

question

EMR

answer

electronic version of the client data found in the traditional medical record

question

Basic Components of the EMR

answer

clinical messaging & email, data repository, and clinical documentation

question

EHR information includes

answer

past medical history, demographics, immunizations, and medication history

question

Bar Code Arm Bands provide

answer

patient health record, medications

question

Registration System

answer

HIS is used to collect and store client identification and demographics data that are verified and updated at the time of each visit

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