Nursing Informatics 2 Notes

Electronic Health Record (EHR)
Integrates all pertinent information into one lifetime record, which will help to improve quality of health information, improve care coordination, patient safety, productivity, contain costs, support research, decrease wait time for treatment, and contribute to the body of healthcare knowledge
-More than an episodic record at an organization

Barriers to EHR implementation
-Development of electronic infrastructure
-Lack of common vocabulary
-Resistance among caregivers
-Lack of IT staff
-Failure to consider organizational change
-Determining a realistic timeline
-Legal issues surrounding the discover of medical information

Standardized Languages
-SNOMED (common language for certified EHRs)
-ICD-10 (billing)

EHR vs. Traditional Paper Records
-Paper records are episode oriented
-Separate for each visit
-Only one person can access at a time
-Cannot incorporate diagnostic studies that include images and sound
-Do not make sure of decision support systems
-Impede collection of data for tracking patient outcomes and comparative effectiveness of research

Advantages of EHR vs. Paper Records
-Increase data integrity and quality
-Increases productivity
-Increases satisfaction for caregivers
-Decreases redundant data collection
-Allows data comparison from prior visits
-Ongoing record
-Supports decision support
-Better/faster data access
-Supports research
-Improved documentation
-Prompts to ensure administration of treatments and medications
-Supports trending
-Better record security
-Instant notice of eligibility / procedure authorization

Disadvantages of EHR vs. Paper Records
-Just because an EHR is implemented does not mean benefits will be achieved
-Rush to implement EHR system for meaningful use compliance can lead to poor purchase decisions and inadequate planning for chance

EHR makes patient care safer by
-Increased medication safety
-Decreased wait time for treatment
-Increased access/ control over health information
-Increase ability to ask informed questions
-Increased responsibility for own care
-Alerts and reminders for appointments and scheduled tests
-Increased satisfaction and understanding of choices

EHR Captures Data For
-Quality improvement
-Utilization review
-Risk management
-Resource planning
-Performance management
-Reimbursement (ICD-10)

Joint Commission
-Continuously improve health care for the public, in collaboration of other stakeholders, by evaluation health care organizations and providing safe and effective care of the highest quality and value

Joint Commission Impact on Nurses
Nations oldest and largest standards setting and accrediting body in health care

Joint Commission Impact on Patients
Consumer advocate and educator, as well as enforcing patient safety

US Agency for Healthcare Research and Quality (AHRQ)
-Electronic documentation could improve quality of care
-To produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable
-Research provides evidence-based information on healthcare outcomes, quality cost, use and access
-Saws electronic documentation could improve quality of life

ANCC Magnet-Role in Healthcare
-High recognition and indicators of quality nursing patient care

Minimum Data Set (MDS)
Documentation that must be complete for compliance and reimbursement with the Joint Commission, medicare, and medicaid
-Includes things like background information, cognitive patterns, communications, medication use and change in status

Personal Health Record (PHR)
-Private, secure application which an individual may access, manage, and share his or her own health information
-Contains information from one’s entire lifetime and from all healthcare providers
-Accessible at any place and any time

Attributes of ideal PHR
-Each person controls his or her own PHR
-PHRs contain information from one’s entire lifetime
-PHRs contain information from all healthcare providers
-PHRs are accessible from any place at any time
-PHRs are transparent; individuals can see who entered each piece of data, where it was transferred form, and who has viewed it

Pros of PHR
-Reduces wait time
-Avoids letters/phone calls
-Allows patients to check and improve quality of medication list

Cons of PHR
-May confuse/worry patients
-May be incomplete or inaccurate if information if from many healthcare providers

Stand alone systems
-Not tied to any healthcare system
Ex: Google Health PHR (discontinued)
Ex: Microsoft Health Vault

Tethered Systems
-Tied into a healthcare system
Ex: My HealtheVet PHR from the VA

PHR combined with EHR
Shared Medical record with patient including:
-Lab and test results
-Medication lists
-After-visit summaries
-Visit notes
-Patient clinical reminders

Best candidates for distance learning
-People in remote locations who cannot get to a school easily

Distance education
-Extends geographic boundaries
-Improves student access
-Meets student demands
-Keep students on the cutting edge of technology
-Remain viable

Meaningful use
Use of health information technology (HIT) legislated by the American Recovery and Reinvestment Act of 2009 to collect specific data with the intent to improve care, engage patients, improve population health, and ensure privacy and security
-Federal incentives allocated for facilities that can demonstrate that they are “meaningfully using” certified EMR technology to improve patient care
-Medicare and Medicaid EMR incentive programs in three stages

Stage 1:
-Focuses on electronic capture and sharing of information
-Record demographic info
-Drug-drug, allergy interaction checker
-Medication list
-Vital signs, BMI, smoking status
-Purchase equipment and start using it (2 years)

Stage 2:
-HIT use at POC for quality improvement
-Lab results as structured data
-Medicine reconciliation
-Submit electronic data to immunization registries
-Have information in, will use it for statistics to help communities

Stage 3:
Improved outcomes and population health

Meaningful use of EHR
-Patient engagement
-Reducing racial disparities
-Improved efficiency
-Increased safety
-Coordination of care
-Measures to improve population health

Eight levels

Lab, pharmacy and radiology are running

Clinical data repository (CDR) exists that allows MDs to view results; controlled medical vocabulary and clinical decision rules engine that checks for conflicts

Basic clinical documentation is present (vital signs, flow sheets)


Closed loop medication administration, BCMA

At least one service has full MD documentation; fully functional PACS (most of the facilities around here)

Paperless environment with fully functional EHR

Basic EMR components
-Results reporting
-Data repository
-Decision support
-Clinical messaging and email
-Order entry

Structured data
-Predefined format (discrete data)
Ex: vital signs, temperature

Unstructured data
-Data that doesn’t follow any particular format and is often provided as text report
Ex: Consultation findings, nurses notes, operative reports, narrative notes

Best database for nursing research

Virtual Learning Environments (VLE)
-Any system that uses the internet to assist the educator in developing, managing, and administering educational materials for students
-May include streaming video, virtual reality or Web 2.0 technology (blogs, podcasts, vodcasts, wikis, youtube)

-Facilitate learning
-Provide tracking capability
-Provide email, chat, and discussion capability
-Blended learning
-Flexibility in scheduling

Advantages of VLE
-Increased retention
-Reduced learning time
-Flexibility of faculty schedules
-Good for viewing EMR documents or steps of a procedure
-Consistent instruction in safe environment
-Improved reading habits
-Available 24 hours a day

Disadvantages of VLE
-Reduced interaction with instructor and peers
-Lack of feedback
-Possibility for poor design and lack of intellectual stimulation
-Bad for hands on instruction

Delivery of content and stimulation of learning primarily through the use of online telecommunication technologies such as blogs, podcasts, video, e-mail, bulletin board systems, electronic whiteboards, inter-relay chat, videoconferencing and the world wide web

Advantages of E-learning
-Available anytime and anywhere there is an internet connection
-Self-paced instruction
-May occur via mobile devices such as PDAs, iPods, or cellular phones

Web-based instruction
-Uses attributes and resources of the WWW for educational purposes
-May be used to supplement traditional courses or as stand-alone instruction
-Used by hospitals for annual education

Advantages of Web-based instruction
-Self-paced learning
-24 hour availability
-Often prompts feedback

Advantages of Simulation Learning
-Standardized student learning opportunities
-Safe learning environment
-Unusual or high risk clinical situations
-Mastery of skills
-Stimulate critical thinking and teamwork

Disadvantages of Simulation Learning
-Initial cost
-Instructor training

Purpose of distance learning
-Improve student access
-Meet student demands
-extend geographic boundaries
-Remain viable
-Keep students on the cutting edge of technology

Mobile Learning
The use of mobile technologies, such as the mobile phone, personal digital assistant (PDA) and iPod for learning purposes
Ex: wiki, podcasts, webinars, virtual meeting spaces

Nurse Use of PDAs
-Used at POC to ensure delivery of safe care
-Reference tools

Nursing Students Use of PDAs
-Reference tool
-Upload clinical tools

Patients Use of PDAs
-Medical diaries or logs
-Reminder messages for medications
-Web access to physicians

Evaluation of online information
-Current revision date
-HON accreditation seal (meets quality standards)
-Source credentials
-Ability to validate information
-Easy to use
-Privacy policy and/or disclaimers

Social Media Use: Nurses
-Professional boundaries (recommend against being friends with patients)
-Job implications

Advantages for Social Media: nurses
-Up to date on organization events, inspiring stories

Disadvantages for Social media: nurses
-Questionable content posted
-Anxiety generation of patient
-Confidentiality issues

Social Media Use: Patients
-Support groups
-Social networking

American Recovery and Reinvestment Act (ARRA) of 2009
-Supports adoption of a nationwide health information infrastructure
-Information technology in general and health information technology
-Obama passed law
-Goal for full implementation by 2014

Electronic Signatures in Global and National Commerce Act (ESIGN) 2000
-Gives electronic signatures the same legal status as handwritten signatures
-Clinton signed it
-To increase e-commerce

Health Insurance and Portability and Accountability Act (HIPAA) of 1996
-Called for the establishment of an electronic patient records system and privacy rules
-Affects all aspects of health information management, including privacy and security of patient records, coding and reimbursement

Makes changes to HIPAA and provides more funding for EHRs

Medicare Improvement Act (MIPPA)
-Provision calling for financial incentives for e-prescribing
-Penalties involved for not e-prescribing
-Gives recommended doses for medication

Patient Protection and Affordable Care Act
-Guarantees access to healthcare for all Americans
-Creates new incentives to change clinical practice and improve quality of care
-Gives practitioners more information to improve practice
-Gives patients more information to make conscious decisions

EHR Incentives
-Medicare and Medicaid have provided financial incentives to physicians and hospitals for meaningful use of health information technology
-Beginning in 2011
-Negative incentives in 2015

Quality initiatives / accreditations

Joint Commission on Accreditation of Healthcare Organization
-Promotes community confidence and improved staff retention
-Shapes practice and documentation

Agency for Healthcare Research and Quality
-Electronic documentation could improve quality of care

Level 0:
Not all ancillary systems operational

Level 1:
Major ancillary clinical systems up

Level 2:
Major ancillary clinical systems + CDR

Level 3:
Some documentation and retrieval

Level 4:
CPOE, support for evidence-based practice

Level 5:
BCMA + identification technology + CPOE

Level 6:
Physician documentation, DS, alerts, PACs

Level 7:
Fully electronic paperless environment

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