NR599: Comprehensive Final Exam 2023/2024

Ethical Decision Making - ANSWERS -Process that requires striking a balance between science and morality. -Making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong. American Nurses Association- Code of Ethics for Nurses with Interpretive Statements. - ANSWERS provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT Bioethical Standards - ANSWERS Autonomy, freedom, veracity, privacy, beneficence, and fidelity are maximally appropriate to the health care setting. Autonomy - ANSWERS The right to choose for himself or herself; respecting the clients opinions, perspectives, values and beliefs. Freedom - ANSWERS The ability of an individual to act independently, without coercion or constraint in ones choice and action veracity - ANSWERS Being completely truthful with patients; a patients right to truth. privacy - ANSWERS The right to be left alone when you want to be, to have control over your own personal possessions, and not to be observed without your consent Beneficence - ANSWERS Actions performed that contribute to the welfare of others; Action of doing good or right by and for the patient. Fidelity - ANSWERS Right to what has been promised; keeping to one's promise. Telehealth - ANSWERS Use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications. Telemedicine - ANSWERS Remote clinical health services mHealth (Mobile Health) - ANSWERS -The practice of medicine and public health supported by mobile devices such as mobile phones, tablets, personal digital assistants and the wireless infrastructure. -The use of wireless communication to support efficiency in public health and clinical practice. Mobile Medical Applications (Apps) - ANSWERS -Accessories to a regulated medical device or are a software that transforms a mobile platform into a regulated medical device. -Facilitates mHealth Medical Devices - ANSWERS Any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients. Rationale APP is NOT Considered Medical Devices - ANSWERS Apps that are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. FDA Oversight for Medical Devices - ANSWERS -Regulatory body that oversees mobile apps that are medical devices and whose functionality could pose a risk to a patient's safety if the mobile app were to not function as intended. -Also oversee the cybersecurity management of these devices as well as the hospital network security. (POC) Point of Care - ANSWERS Testing and diagnosis at the patient's side and can be conducted anywhere the patient is, such as the home, physician office, ambulance, or hospital bedside Privacy - ANSWERS Practice of maintaining the security and confidentiality of patient records. Confidentiality - ANSWERS The act of holding information in confidence, not to be released to unauthorized individuals. Cybersecurity - ANSWERS -Measures taken to protect a computer or computer system against unauthorized access or attack. -FDA is main regulatory agency Computer-aided Translators - ANSWERS Language translation in which a human translator uses computer hardware to support and facilitate the translation process. HIPPA (Health Insurance Portability and Accountability Act) - ANSWERS Enacted in 1996; federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. ICD-10 Codes - ANSWERS -Alphanumeric codes used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses. -Shorthand for the patient's diagnosis , which are used to provide the payer information on the necessity of the visit or procedure performed CPT Codes (current procedural terminology) - ANSWERS official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non-physician providers Evaluation and Management Coding - ANSWERS process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing. Necessity for establishing E/M Codes - ANSWERS Place of Service; Type of Service; Patient Status Components of Risk Based E/M Coding - ANSWERS History; Physical; Medical Decision Making Medical Decision Making (MDM) - ANSWERS 1 of 3 components to establishing E/M codes; way of quantifying the complexity of thinking that is required for the visit. 3 key elements to medical decision making - ANSWERS risk, data, and diagnosis Reimbursement Coding - ANSWERS -Claims and documentation filed by providers using medical diagnosis and procedure codes. -Assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders. Clinical Support Tools - ANSWERS -Found in EHR software that when applied effectively, can enhance patient care quality and outcomes, improve efficiency, and help to ensure regulatory compliance. -Process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assessments, recommendations, or other forms of guidance for clinicians, patients, and others involved in care delivery. Alert Fatigue - ANSWERS Main challenge to effective implementation of CDS Tools Primary Goal of CDS Tools - ANSWERS leverage data and the scientific evidence to help guide appropriate decision making. Workflow - ANSWERS -Term used to describe the action or execution of a series of tasks in a prescribed sequence. -The progression of steps (tasks, events, interactions) that constitute a work process, involve two or more persons, and create or add value to the organization's activities. -Used interchangeably w/ process or process flows; Workflow Analysis - ANSWERS -Study of the way work (inputs, activities, and outputs) moves through an organization. -Observation and documentation of workflow to better understand what is happening in the current environment and how it can be altered Sequential Workflow - ANSWERS each step depends on the occurrence of the previous step Parallel workflow - ANSWERS two or more steps in a process can occur concurrently. Workflow design - ANSWERS A critical aspect of the informatics role in workflow analysis American Recovery and Reinvestment Act of 2009 (ARRA) - ANSWERS -provided funds to government agencies for improving information-technology systems; -provisions include the right for every person to receive an electronic copy of their EHR and to have a copy of their EHR transmitted to a party that they designate Patient Protection and Affordable Care Act (ACA) - ANSWERS Guarantees healthcare for all Americans, expands Medicaid, provides incentives intended to improve care coordination and quality, restructures healthcare payment, and provides additional information to patients so that they can make value-based decisions. Administrative Data - ANSWERS Include billing information derived from insurance claims, inpatient discharges (or hospital bills), and outpatient visits. National Prevention Strategy: America's Plan for Better Health and Wellness - ANSWERS comprehensive plan that sets forth evidence-based and achievable means for improving health for all Americans at every stage of life. These efforts are designed to stop disease before it starts and to create strategies for a healthy and fit nation, recognizing that prevention must be part of daily life. Fee-for-Service Model - ANSWERS a provider is given a set amount of monetary reimbursement for a specific visit or procedure performed that is adjusted for geographical location Medical Coding - ANSWERS use of codes to communicate with payers about which procedures were performed and why . Medical Billing - ANSWERS process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider general principles of nursing informatics - ANSWERS essential skills related to informatics deemed appropriate nursing informatics - ANSWERS integrates nursing science with multiple information and analytical sciences to identify define manage and communicate data information knowledge and wisdom and nursing practice nomenclature - ANSWERS naming system classification system - ANSWERS assistant that captures categories that are used for cost or clinical documentation international statistical classification of diseases and related health problems ( ICD ) - ANSWERS ICD is used as a standard terminology (ST) parentheses not always accepted Standard Terminology - ANSWERS structured controlled languages developed to represent concepts in a given domain in a clear fashion Taxonomy - ANSWERS uses classification according to a predetermined system to provide a framework for discussion Data Set - ANSWERS a named collection of data consisting of individual information organized in a prescribed fashion benefits of using a data set - ANSWERS efficiency accuracy and effectiveness resulting in improved patient care and outcomes has an effect on cost information visibility and transformation / health care reform knowledge - ANSWERS The awareness and understanding of a set of information and ways that information can be made useful to support a specific task or arrive at a decision wisdom - ANSWERS -knowledge applied in a practical way -the highest form of common sense -entails knowing when and how to apply knowledge -It is through efforts to understand the nature of knowledge in its evolution that one can conceive of build and implement informatics tools to enhance and mimic the mind's processes to facilitate decision-making and job performance scientific underpinning - ANSWERS The foundation of nursing science through research data evidence and idea creation The foundation of knowledge model - ANSWERS A model proposing that humans are organic information systems constantly acquiring, processing, generating, and disseminating information or knowledge in both their professional and personal lives computer science - ANSWERS studies the theory underpinning information and computation and their implementation and computer systems cognitive science - ANSWERS how the human mind works from an information processing perspective information science - ANSWERS The retrieval and management of information as well as human computer interaction two types of informatics competencies - ANSWERS 1. generalist- knowledgeable with experience 2. nurse specialist- graduate level education specialized education information literacy - ANSWERS The ability to identify when information is needed as well as the skills to find evaluate ineffectively use the same information health literacy - ANSWERS The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions meaningful use - ANSWERS using technology and health information to increase the quality of care delivered patient-centered information systems - ANSWERS patient centered information systems focused on collecting data and disseminating information related to direct care four most common types of PCS systems - ANSWERS clinical documentation systems pharmacy information systems laboratory information systems radiology information systems clinical decision support systems - ANSWERS a computer-based program designed to assist clinicians in making clinical decisions by filtering or integrating vast amounts of information and providing suggestions for clinical intervention electronic medical records / electronic health record - ANSWERS a database of an individual's healthcare data during healthcare encounters and/or comprised of any patient data stored in electronic form electronic health record system - ANSWERS The database management software enabling the many functions needed to create and maintain an EHR POE/CPOE/CDS - ANSWERS POE- practitioner order entry, CPOE- computerized practitioner order entry, CDS- clinical decision support human technology interface - ANSWERS The hardware and software through which the user interacts with any technology. for example computers patient monitors and telephones. The human technology interface addresses the user's ability and the technologies functionality to complete the task demand. health information technologies ( h i t ) - ANSWERS hardware software integrated technologies are related licenses intellectual property upgrades or packaged solutions sold as services that are designed for or support the use by healthcare entities or patients for the electronic creation maintenance access or exchange of health information alarm fatigue - ANSWERS multiple false alarms by smart technology that cause workers to ignore or respond slowly to them digital natives - ANSWERS a person born or brought up during the age of digital technology and therefore familiar with computers and the internet from an early age information literacy competency standards for nursing - ANSWERS able to recognize when information is needed and having the ability to locate evaluate and use effectively the needed information HITECH Act of 2009 - ANSWERS -Provided incentive payments to hospitals and healthcare providers to adopt health IT. tiger based nursing informatics competencies model - ANSWERS -technology informatics guiding education reform team -a plan to include informatics courses and all levels of nursing education when the effort is complete they will examine how to get the information out to practicing nurses who are not currently enrolled in an academic program meaningful use - ANSWERS the use