NSG 310 TOPIC 12 FINAL EXAMS

NSG 310 TOPIC 12 FINAL EXAMS Topic 12: Health Care Information Systems and Management I 1. Describe documentation systems in various settings. • EHR –has been used as a generic term for all electronic health care records in document systems that are portable (can follow client to other providers, specialists, other hospitals, nursing homes, etc. • EMR – legal record created in hospitals and ambulatory environments that is the source of data for the HER at that facility • HIT – Health information technology provides improved communication flow that is fast, timely, and available to all stakeholders (docs, nurses, client/family, pharmacy, etc.) • CPOE – Computerized provider order entry = systems put into place for safety • CDSS – clinical decision support provided via data collected on client to help team with clinical decisions • Centers for Medicare and Medicaid Services (CMS) have set up Health Information Technology standards in US • PHR – Patient healthcare record: information that can be managed by the client o Clients can create their own records from collection of visit information from a variety of providers o Clients can access their own records from healthcare provider web based encrypted sites to view and print o The systems set up from providers contain personal healthcare records that are private just for consumers and not shared; however, client can take that information and share it with another provider o In some cases, clients can add to their providers information for the EHR kept by that provider (i.e. scan in labs or other healthcare information from another provider for primary provider records) 2. Identify standard components of the electronic medical record (EMR). • Attributes identified by the Institute of Medicine (IOM) provide the basis for today’s understanding of the EHR o Secure, reliable access where and when needed o Records and manages episodic & longitudinal information o Primary information source during care o Assists with planning and delivery of evidence-based care • Captures data for: o Quality improvement, utilization review, risk management, resource planning, performance management • EHR components o Information needed for medical record and reimbursement purposes o Longitudinal, masked information supports clinical research, public health reporting, and population health initiatives o Supports clinical trials and evidence-based research o Client safety & security of private health information o Restructures healthcare delivery system to improve the quality of care o Cost containment 3. Explain the role of the EMR as a legal document, including nursing responsibilities. • Healthcare records are legal documents • Criminal investigations • Financial impact • Keep it confidential – Privacy laws o Residence information o Ethnicity/Sex/Birthdate o Possibly whole or part of SSN o Diagnosis • Cyber-crimes are on the rise • Data contains personal client information • Protect from unauthorized users • Maintain secure password management • Automatized sign on (scanners) • Grant access only on need to know basis • Maintain professionalism • Misuse & Consequences o Negative comments may constitute hostile environment o Civil and criminal penalties o Fines/jail time o Personal liability o Termination of employment o Poor publicity for hospital o Board of Nursing will investigate mismanagement of client records, unethical conduct, and breaches in confidentiality 4. Determine how nurses integrate data management into daily nursing practice. • Nursing role in healthcare with HIT o Lead and assist in IT development o Timely, accessible documentation o Reduce medication errors o Collaborate with physicians/other team members o Assist in policy development o Data mining/research for best practices • EHR documentation o Why do I document? o Show client response to care o Compile date from many clients to identify “best practice” o Give evidence for reimbursement o Provide proof of quality care o Make a permanent record of care given • In nursing, system for medication dispensation are used, such as the Pyxis, which holds most of the medications available to the nurse on the client care unit. Each medication is held in a different pocket of a drawer which the pharmacy fills. The machine can be extended with more sections to provide more drawer space, and refrigerated sections, if needed. When nurses need a medication for a client, they will sign in to the machine and choose the correct client and the correct medication. The machine will determine if the medication is ordered, and if it is within the appropriate timeframe for the medication. It will then open the correct drawer for medication removal. • Medications can be returned for credit to the client using the system process if they are not given. The medications are refilled by pharmacy on a routine schedule. Medications not in the machine can be requested directly from pharmacy. Medications that a client is taking for more than one or two doses will be stocked in the machine for the nurse to pull. There is usually one machine for each nursing unit, with larger units having two or three. Note, some meds require two nurses to enter their ID for dispensation of particular meds. • Some ICU’s/ED’s and units have bedside monitoring devices o Bedside vital signs monitor connect direct to the EMR o Nurse takes vitals which are imported directly into the chart o VS flowsheets can be reviewed for comparisons of one or more selected vitals made into chart (visualized as list or graph) • Glucometers may come with a docking station o Serves as a charger o Serves as a connection to the EMR logging in BS readings o Chart/graphs can be viewed/reports generated • Medication errors: The most frequent cause of adverse medication events which are preventable • Technology which improves medication safety o Computerized physician order entry (CPOE) o Barcode medication administration (BCMA) o Electronic medication administration record (eMAR) • Laws from FDA require drug manufacturers to label all meds with barcodes since 2004 o Has increased incentives for facilities to utilize technology • Each medication that is used bears a bar-code o Applied by pharmacy o Is coupled to a medication in the EMR ordering system • Nurse medication administration o Medication is scanned by a hand-held device that either is connected by wire to the computer or is Wi-Fi transmitted. o Nurse scans the client ID on arm band o The computer will verify that the right medication was given to the right client at the right time, via the right route, at the right dose, right documentation • BCMA serves as a secondary check -- nurse is responsible to check the 6 rights! • The HIPAA Privacy Rule gives individuals who are the subject of a medical record (held by a covered entity such as a healthcare provider)the right to access their record, amend the record, obtain a copy, and direct that the record be provided to other healthcare providers. However, while the HIPAA Privacy Rule protects the privacy of individually identifiable information, individuals do not “own” the record and cannot take it from the provider or have it destroyed. The same principles apply to information contained in a provider’s electronic medical record (EMR). Topic 13: Health Care Information Systems and Management II 1. Identify how data management, analysis, and mining are used in health care. • Data management - compiling information for data entry into a database for evaluation o Data management - Data entry, data review, charting, updating, and editing data • Analysis - putting data into formats for interpretation and research including qualitative and quantitative categories to show results of care o Analysis - Interpretation of progression of condition in the EMR, discovering related manifestations from data in EMR, drawing conclusions about plan of care from analysis of patient history and evaluation • Data mining - researching sources for hidden data that can help determine outcomes and find more effective treatment plans o Data Mining - Looking at percentiles, results, trends, patient progress notes, and errors of staff that can help the office to improve their care ▪ this is every patient not just one 2. Identify common sources of reliable data and information related to nursing and evidencebased practice. • Electronic databases • Cumulative Index to Nursing and Allied Health Record (CINAHL) • Hand held computers • Tablets • Smart phones • Medical apps • American Psychological Association (APA) • Citation Management Tools-EndNote RefWorks • EBP STEPS: • Ask a clinical question • Search for the best evidence • Critically appraise the evidence • Integrate the evidence • Evaluate the outcomes • Disseminate EBP results • Share the info/results with other people • Documentation systems in the hospital setting o Help with data management o Information is secure and localized o Create accountability for actions o Increase efficiency • Documentation is used for o Organization - staying on top of charts & patient needs o Prioritizing patients - knowing what must be addressed first o Communication - enhances collaboration & quality of care o Charting - can help reduce medical errors if done properly • Healthcare is driven by data • Data mining is becoming more popular in health care o Data mining involves finding patterns in data to make educated predictions o Measuring treatment effectiveness: allows for the signs and symptoms of a patient to be analyzed and the most beneficial course of treatment to be recommended o Patterns of infection, adverse effects, and treatment effectiveness are all things that can be tracked o Fraud and abuse can be detected from inappropriate referrals, claims, prescriptions o Data mining success is dependent on: ▪ Standardization ▪ Investment in resources ▪ Buy in from healthcare providers ▪ Skilled team • Documentation o Electronic Health Record (EHR)-transparent nursing process o Interrupted workflow vs. improved standardized records o Easy access to health care providers • Information Technology o Nursing care alerts o Facilitates data analysis o Automatic summaries • Informatics o Links information technology to nursing standards o User-friendly sessions for nurses • Medical Safety o Errors can be both human and electronic o Overall electronic documentation, health IT, and informatics prove beneficial to patient care • Standards of Practice o Improved structure yields improved quality care o Adequately measure staffing needs • What Information is Protected by Federal Law? o Any information in a personal Medical Record o Information found in health insurer’s computer system o Personal billing information • What Can We Do as Nurses? o Speak quietly in public setting o Avoid using names when possible o Lock file cabinet with information/ LOGOUT of electronic medical records • Computerized physician order entry (CPOE) is the process of a medical professional entering medication orders or other physician instructions electronically instead of on paper charts. A primary benefit of CPOE is that it can help reduce errors related to poor handwriting or transcription of medication orders. o Vulnerability of wrong-patient errors o Lack of standardized alerts o Abundance of irrelevant alerts o Safety concerns o Cost Topic 14: Informatics and the Role of the Nurse 1. Define informatics. • What IS Nursing Informatics? The American Nurses Association said that it “combines nursing, information, and computer sciences for the purpose of managing and communicating data, information, knowledge, and wisdom to support nurses and healthcare providers in decision making”. • Data are single points of information, such as the blood pressure or the pulse rate. • Information is putting the data in context – e.g. looking at all of the client’s vital signs. It is putting all data about the client into the context of ONE client. • Knowledge is knowing how and why things work, so that the nurse can understand that the blood pressure and the trend are abnormal. • Wisdom – Having Knowledge internalized and understanding what needs to be done. o Wisdom also helps prioritize clients -- Which client is the most critical and needs immediate attention, and who can wait? • Specialist – facility specific • Analyst – facility or healthcare system • Consultant – healthcare system or independent 2. Identify basic research skills for finding nursing statistics and data. • Specialist role o Implement informatics solutions o Project management, project coordination o Liaison between end users and programmers o Test and document systems o Translate user requirements for programmers and engineers o Provide input for software and hardware design o Write user manuals o Adhere to national and international standards • Analyst role o Analyze technical design o Analyze functional design o Make recommendations for developing new software o Assess organizational needs o Predict organizational needs • Consultant role o Provide input and assistance and be a resource o Provide unbiased input to organization o Design, plan, and implement informatics solutions o Evaluate clinical software o Write publications, education courses o May wear multiple hats – researcher, educator, project manager 3. Articulate connections between informatics and effective communication and the provision of safe, quality care. • Client Hospital Record = Electronic Medical Record • BCMA – The Pennsylvania Patient Safety Authority reports that: o 39% of errors occur during prescription, and o 38% occur during administration. That means that health care providers and nurses are responsible for 77% of medication errors. 4. Forecast future informatics trends and issues that affect the health care industry. • Bar-Coded Medication Administration (BCMA) o Studies show 65% - 86% decrease in med errors o In a 2007 report, BCMA decreased dispensing error rate by 31%, or 13,500 errors • Dictation – Many hospitals are using Dragon Naturally Speaking to do their documentation, at least for their health care providers. It is much faster to talk into a microphone to do your documentation than it is to write or type it out. Dragon is good at converting speech into typing on the computer, but it isn’t 100% yet. As it gets closer to 100%, we will most likely be seeing more facilities using it. • Expert Systems – There are now systems being investigated to actually do the thinking that a nurse or health care provider would do. The system can evaluate the client’s labs, EKG, ventilator settings, vitals, even the care plan. When it does, it can use algorithms to determine the best course of treatment for the client. It can write out orders and create a nursing care plan. o (Remember that knowledge is information that has been synthesized so that relationships are identified and formalized – Interpreting & understanding the information). • Clinical Decision Support Systems– One way the research on expert systems is coming into the world of real clients is through decision support. Every order that is placed, every care plan that is created, can be reviewed by the computer, which will then suggest changes or additions based on what it knows about the client and the conditions the client has. Some examples – an order is placed for a client on a ventilator. The computer looks up when the last Blood Gas test was done, and if it has been more than the prescribed time, it will remind the person putting in the order to consider it. If the client is in for surgery on their leg and there is no Fall Risk careplan created yet, the computer can suggest it to the nurse charting. • Automatic Charting - Envision a world where you walk into a client’s room and the electronic chart opens automatically for you, because the computer knows who you are and where you are, and can associate that with the correct client. Perhaps one day image processing will be advanced enough that the nurse wouldn’t even have to speak to have her/his tasks charted as complete. Just by performing a task, the computer will be able to analyze what the nurse did and chart it for her/him, for her/his review later. • PHR- ‘‘electronic tool that. . .enables individuals or their authorized representatives to control personal health information, supports them in managing their health and wellbeing, and enhances their interactions with health care professionals.’’ • Patient health records keep a person’s entire medical record. This includes health care provider’s notes, the entire hospital record, and lab and x-ray results. • Patient Portal – The first stop on the road to giving clients more control of their health and health records is the Patient Portal. The portal is an electronic resource supplied by a hospital or company to allow clients to access customized material related to their health. o Patient Education o Maintain medical records o Allows client to set reminders o Communicate via e-mail with health care provider • Patient Teaching – The internet is something almost every person has experience with. Teaching is a major job of nurses, and the internet is a perfect opportunity for the nurse to help the client take a more active role in their care. As the nurse taking care of the client, it may be up to you to teach your client how to use the internet to search for information. You may also have to teach them not to trust everything they read on the internet. Clients will have questions about what they should be doing, or their meds, or something they read, and nurses can help answer those questions