Chapter 18: Nursing Informatics – Flashcards
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asymmetrical information
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individuals on one side of the transaction may have much better information than those on the other; it uses multiple sources of data in economics and business to gain an advantage
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informed decisions produce
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better outcomes
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who has the advantage?
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the person with more information
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ACA
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affordable care act
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the ACA stresses
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the need to reduce costs
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competition is the
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driving force in the pricing and marketing of health care
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payment methods that promote competition
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medicare and medicaid, PPSs, HMOs, PPOs
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PPSs
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prospective payment systems
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HMOs
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health maintenance organizations
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PPOs
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preferred provider organizations
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technology driven organizations have a
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competitive driven edge
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health care, the health care delivery system, and nursing must
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open themselves up to new information and ideas
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medical informatics
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all the informational technologies that deal with the medical care of the client, medical resources, and the decision making process
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health informatics
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the use of information technology with information management concepts and methods to support the delivery of health care (includes medical informatics)
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nursing informatics
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the content and application of nursing information is substantively different from that of other disciplines
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early model of nursing informatics views nursing informatics primarily as
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combining computer science and information science and nursing science in a manner that wold help the nurse in the planning and delivery of care to clients
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newer models of nursing add a forth element:
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cognitive science
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cognitive science
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combines psychology, linguistics, computer science, philosophy, and neuroscience to help deliver client care; it is also concerned with perception, thinking, understanding and remembering
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data
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raw and unstructured fact
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information
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data that have been given form and have been interpreted
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knowledge
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a synthesis of data and information used to make a decision about what treatment should be given; relies on critical-thinking and decision-making skills
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areas of focus in informatics
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technology, nursing theory, and function
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ANA definition of informatics
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a nursing specialty that integrates nursing science, computer science, and information science to identify, collect, process, and manage data and information in support of nursing practice, administration, education and research and to expand nursing knowledge
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ANA purposes of informatics
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to analyze information requirements, to design, implement, and evaluate information systems and data structures that support nursing, to identify and apply computer technologies for nursing and to be recognized as a nursing specialty with certification
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the need for a standard
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nurses had difficulty in locating relevant nursing information quickly because there was no universally agreed upon nomenclature and taxonomy for either nursing clinical information or management of data
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unified nursing language system
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ANA database steering committee developed a common nursing language called the Unified Nursing Language system
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UNLS
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Unified Nursing Language system developed by the ANA database steering committee
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UNLS maps
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concepts and identifies common terms from different vocabularies and recognizes them as synonyms of the same concept
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What does NMDS stand for
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Nursing Minimum Data Set
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NMDS
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a list of the data elements necessary for all computerized client record systems or national databases
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the NMDS is considered to be
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the umbrella for other nursing process systems
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traditionally, nurses have not been very good at
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documenting their wroth and effectiveness
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to measure effectiveness with accurate information about client care and outcomes,
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nurses must use standardized language in both practice and documentation
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this process forms the basis for
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accountability/ credibility
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the ACA places focus on
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positive outcomes for quality client care
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credibility of the nursing profession rests on
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its ability to document how nursing care improves clients' health and saves money for health care institutions
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nurses must be able to
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measure their effectiveness with accurate information about both the care given and the client outcomes achieved
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an information explosions
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the amount of health-care information contained in scientific journals has grown to a point where no single individual is able to read all of the material
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one new article is added to the medical literature every
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26 seconds
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evidence based practice (EBP)
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although a large amount of new informatics is available, only a small portion is read by and incorporated into practice of many health care professionals
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nurses no longer have to
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leave the practice setting and go to the library to access relevant information
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literature can be searched from
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the nurses' station or even the client's bedside using available information systems
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nursed find that
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having access to literature about clinical issues increases their confidence levels in providing high quality care
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Using EBP includes
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accessing current literature concerning the latest diagnostic techniques and treatment modalities, conferring with a knowledgable colleague, and evaluating the effectiveness of previous experiences
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the human factor
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is the system user-friendly? does the system make sense? is the system well designed?
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access to the electronic health record creates
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a bedside system and a point of care system
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bedside system
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computer terminal installed in each client's room or next to each bed
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point of care system
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includes not only the bedside, but also many other points of care in the health-care environment and community, including the laboratory, radiology department, outpatient clinics, and even the home for home health care providers; handheld devices facilitate point of care systems
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advantages of the electronic health record
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accessible form remote sites, accessible to multiple users at the same time, provides reminders about completing information or carrying out protocols, reduces redundancy, and improves communication
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disadvantages of the electronic health record
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high start up cost, steep learning curve, subject to glitches, and unresolved issues about privacy and access
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who owns the clients health care data?
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HIPAA says that the client owns it; only can be released with permission but in reality access to information is easy for many groups
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what does HIPAA stand for
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health insurance portability and accountability act
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primary goals of HIPAA
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ensuring people can take their insurance with them when they go to a new job, reducing health care fraud and abuse, guaranteeing security and privacy of health information, and enforcing standards for health information
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unauthorized sharing of health care information is unethical and since HIPAA, it is also...
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illegal
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the code of ethics prohibits
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unauthorized or unnecessary access to client information
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confidentiality is the basis of
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trust in a therapeutic relationship
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threats to security
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either accidental or intentional damage to paper and electronic health record
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threats include
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floods, tornadoes, fires, earthquakes, electrical surges/power outages, and acts of terror
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intentional acts
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the actions of an individual or individuals who wish to damage, destroy or alter the record
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paper records are easy to:
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erase or white out, add to, rewrite sections of the chart, remove the chart and destroy it, makes changes that are often very difficult to detect
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electronic records are
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overall more secure than the paper record
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electronic systems have
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computer virus-checking program that protect the automated record from both intentional and accidental introduction of destructive computer viruses into the system
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WORM programs
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"Write once, Read many" prevent changes to records
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uses of the internet
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a resource for professionals, a guide for consumers
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a resource for professional
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courses, postion vacancies, conferences, information about facilities, CEU causes, policy statements, and lists of publications
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a guide for consumers
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preventive and wellness services, medication purchasing, health and human services information, government publications, clearinghouses, databases
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tele heath
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health care at a distance
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physicians examine and treat clients from distant sites with
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video cameras, thus saving money by exchanging office visits for online appointments
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telehealth is used in
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emergency room, telesurgery
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telehealth serves
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remote populations
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challenges for the future
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system design, expense, legal issues, effects on nursing practice, and education and conferencing
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system design
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updating old systems
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expenses
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third party payment ?
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legal issues
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licensure issues
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effects on nursing practice
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more autonomy
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education and conferencing
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distance and nontraditional education
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