Textbook Notes Flashcards
(110 cards)
1
Q
There are foundational skills that are required for an information-driven culture. These include ___ literacy, ___ literacy, and (for the consumer), ___ literacy.
A
computer, information, health
2
Q
Without computer literacy, ___ cannot be accessed/addressed
A
the other forms of literacy (information, health)
3
Q
Joint Commission International (2017) lists six patient safety goals that focus upon correct ___, effective ___, improved safety of ___ medications, procedures that do not ___, decreased risk of ___, and reduced risks of harm secondary to ___.
A
identification, communication, high-alert, introduce harm, healthcare-acquired infections, falls
4
Q
HIT can improve safety and quality through alerts and decision support that help to improve the ___ process—a point where many errors occur—and through the use of ___.
A
hand-off, checklists
5
Q
___ errors include mistakes, slips, and lapses made by ___, while ___ errors occur with imperfect organization design such as those seen with incomplete procedures, poor training, and poor labeling.
A
Active, clinicians, latent
6
Q
Administrative information systems (AIS) support client care by managing ___ and ___ information and providing ___ capabilities.
A
financial, demographic, reporting
7
Q
___ information systems (___) focus on management of clinical (patient) data and information as compared to ___ information systems.
A
Clinical (CIS), administrative (AIS)
8
Q
Client scheduling and discharge would be part of the ___ information systems (___)
A
administrative (AIS)
9
Q
___ systems focus upon the acquisition, review, and use of patient data. Functions may include order entry, results-reporting, scheduling, and documentation.
A
Clinical information systems (CISs)
10
Q
___ systems can include registration and scheduling; tracking through admission, transfer and discharge; patient acuity and staff scheduling; financial or accounting systems; risk management; payroll and human resources; quality assur-ance; and contract management functions.
A
Administrative (AIS)
11
Q
The American Recovery and Reinvestment Act (ARRA) of 2009 included the Health Information Technology for Economic and Clinical Health Act (HITECH), which authorized incentive payments to specific types of hospitals and healthcare professionals for adopting and using ___
A
interoperable health information technology and EHRS
12
Q
(In addition to the standard requirements) MU included a menu of ___ other EHR tasks from which providers could choose to implement ___ in 2011 to 2012.
A
10, 5
13
Q
The Centers for Medicare and Medicaid Services (CMS) developed core criteria that defined basic functions EHRSs must demonstrate, including: basic entry of ___ such as demographic data, vital signs, medications, and allergies; use of several ___ that begin to realize the true potential of EHRSs to improve the safety, quality, and efficiency of care through clinical decision support; and entry of ___ with safety measures within the software.
A
clinical information, software applications, clinical orders
14
Q
The Medicare and Medicaid EHR Incentive Programs include ___ stages with increasing requirements for participation.
A
three
15
Q
What is a goal of the health information exchange (HIE)?
A
data sharing between providers, patients, insurance, etc.
16
Q
Nurse informaticists, sometimes called ___ nurses, work in the interdisciplinary area of ___ in healthcare organizations. They organize patient care software and electronic medical records, using their clinical nursing knowledge to optimize these systems.
A
informatics nurses
information technology (IT)
17
Q
A clinical systems vendor and a medical device manufacturer would be likely to employ a ___ nurse
A
informatics
18
Q
Duplicate orders cause quality issues in patient care.
What helps to resolve this problem?
A
Providing training and reminders
19
Q
The HIMSS Electronic Medical Record Adoption Model (EMRAM) is exclusively designed to assess ___. It is used for ___ only. To assess ___ communities, refer to HIMSS ___
A
acute hospital settings, inpatients only
outpatient, HIMSS Outpatient EMRAM (O-EMRAM)
20
Q
___ is a/an eight stage model used to assess ___ for hospitals and health systems
Rated from 0 to 7
A
EMRAM (Electronic Medical Record Adoption Model)
EMR implementation and adoption
21
Q
The benefits of interoperability include increased ___, reduced ___, and reduced ___.
A
productivity, costs, errors
22
Q
Codes which support outpatient billing
A
Current procedural terminology (CPT)
23
Q
One major benefit of nursing informatics is that it improves ___ among the healthcare team to improve ___.
A
communication, outcomes
24
Q
What reduces and organizes terms for easier searches
A
Taxonomic vocabularies
25
A ___ is typically a controlled vocabulary with a hierarchical structure, with the understanding that there are different definitions of a hierarchy. Included terms have relations to other terms within. These are typically: parent/broader term, child/narrower term, or often both if the term is at mid-level within a hierarchy.
taxonomy
26
**A provider electronically orders blood work at a laboratory. The provider must ensure the local lab system can properly communicate with the provider’s system for the results to be usable.**
**Which is the correct term that would be found in these systems?**
Logical observation identifiers names and codes (LOINC)
27
The Logical Observation Identifiers, Names, and Codes (LOINC) is a terminology that includes ___ and ___ observations.
laboratory, clinical
28
\_\_\_ is:
* A common language (set of identifiers, names, and codes) for clinical and laboratory observations.
* A rich catalog of measurements, including laboratory tests, clinical measures like vital signs and anthropomorphic measures, standardized survey instruments, and more.
* A standard which enables the exchange and aggregation of clinical results for care delivery, outcomes management, and research by providing a set of universal codes and structured names to unambiguously identify things you can ___ or \_\_\_.
LOINC
measure or observe
28
\_\_\_ is:
* A common language (set of identifiers, names, and codes) for clinical and laboratory observations.
* A rich catalog of measurements, including laboratory tests, clinical measures like vital signs and anthropomorphic measures, standardized survey instruments, and more.
* A standard which enables the exchange and aggregation of clinical results for care delivery, outcomes management, and research by providing a set of universal codes and structured names to unambiguously identify things you can ___ or \_\_\_.
LOINC
measure or observe
29
\_\_\_ is a set of ___ standards used to transfer and share data between various healthcare providers. More specifically, it helps bridge the gap between health IT applications and makes sharing healthcare data easier and more efficient when compared to older methods.
HL7
international
30
**\_\_\_ interoperability**
The ability to exchange the data from one point to another
Technical
31
**\_\_\_ interoperability**
The exchange of data in which the meaning remains the same on both ends of the transaction
Semantic
32
**\_\_\_ interoperability**
Coordinates systems enabling business processes at the organization(s), and allowing the systems to work together
Process
33
**\_\_\_**
The ability of two or more systems to pass information between them and use the exchanged information
Interoperability
34
A patient is being transferred to a trauma hospital in the area. The current hospital uses a different electronic health record (EHR) than the receiving hospital.
Which process allows interoperability of the health information exchange (HIE) between the two hospital systems?
Consolidated-Clinical Document Architecture (C-CDA)
35
**Which measure is included in the vital signs section, in addition to temperature, blood pressure, respiration, and heart rate?**
(the 5th vital sign)
Pain scale
36
**What is the meaning of confidentiality of patient records**
A healthcare provider can disclose health information with specific permission.
37
**What are three types of networks or information exchanges?**
Local area network (LAN)
internet
wide area network (WAN)
38
**How does an informatics nurse institute manual and automated procedures to manage data security, accuracy, and integrity?**
Monitors patterns and exceptions
39
\_\_\_ is a not-for-profit, membership-based organization that works to improve healthcare through meaningful measurement
NQF
40
**Which merit-based incentive payment system (MIPS) category replaces the reporting program that assesses care provided to Medicare patients, to ensure patients get the right care at the right time?**
Quality
41
MIPS (Merit-based Incentive Pay System) includes four performance categories: \_\_\_, \_\_\_, ___ \_\_\_, and Promoting ___ (formerly ___ \_\_\_)
Quality, Cost, Improvement Activities, and Promoting Interoperability (formerly Meaningful Use)
42
**What are two items that exempt eligible clinicians from a merit-based incentive payment system (MIPS)**
Low-threshold provider who bills Medicare less than $90,000 yearly
Two hundred or fewer Medicare patients seen annually
43
In the context of health IT, meaningful use is a term used to define \_\_\_
minimum U.S. government standards for electronic health records (EHR)
44
Meaningful use Stage 1
\_\_\_ to \_\_\_
Data ___ and \_\_\_
45
Meaningful use Stage 2
20\_\_
Advance ___ \_\_\_
46
Meaningful use Stage 3
20\_\_
Improved \_\_\_
47
Five rights of Clinical Decision Support (CDS)
(Hint: Right ___to the right___ in the right ___through the right___ at the right ___in___)
1. The ***right information***: evidence-based, suitable to guide action, pertinent to the circumstance
2. To the ***right person**:* considering all members of the care team, including clinicians, patients, and their caretakers
3. In the ***right CDS intervention format***: such as an alert, order set, or reference information to answer a clinical question
4. Through the ***right channel***: for example, a clinical information system (CIS) such as an electronic medical record (EMR), personal health record (PHR), or a more general channel such as the Internet or a mobile device
5. At the ***right time in workflow***: for example, at time of decision/action/need
48
**What can healthcare staff do to keep patient information that has been accessed with a mobile device protected?**
Install device updates when available
49
**Which mobile device feature may reside on a device indefinitely**
Text messages
50
**What is the correct order of the system development life cycle phases**
Designing, planning, implementation, analysis, evaluate
51
\_\_\_ ___ helps prioritize limited resources and ensures system standards are upheld.
Change control
52
**Which phase of implementation uses small groups of individuals to evaluate potential issues that may occur when making a new systems transition**
Pilot phase
53
When a new system is adopted instantly, with no transition period between the old and new systems (two terms)
Big bang adoption or direct changeover
54
\_\_\_ conversion operates both the old and the new system for a limited time. ___ conversion changes to the new system in phases, introducing some of the new applications while still using some of the old applications, or converting some departments or locations at a time.
Parallel, Phased
55
**Kurt Lewin** developed a change model involving three steps: \_\_\_, ___ and \_\_\_.
**unfreezing, changing, refreezing**
The process of change entails creating the perception that a change is needed, then moving toward the new, desired level of behavior and finally, solidifying that new behavior as the norm. The model is still widely used and serves as the basis for many modern change models.
56
“\_\_\_ is the right to control access and disclosure or nondisclosure of information pertaining to oneself and to control the circumstances, timing, and extent to which information may be disclosed"
Privacy
57
The Technology ___ Guiding Education Reform (TIGER) Initiative was established in 2006 in the United States to develop key areas of informatics in nursing. One of these was to integrate ___ competencies into nursing curricula and life-long learning.
Informatics, informatics
58
\_\_\_ ___ is a process in which organizational leaders determine their vision for the future as well as identify their goals and objectives for the organization
Strategic planning
59
A ___ Statement defines the company's business, its objectives and its approach to reach those objectives. A ___ Statement describes the desired future position of the company.
Mission, Vision
60
**The 5 basic phases in the project management process are:**
* Project \_\_\_
* Project \_\_\_
* Project \_\_\_
* Project \_\_\_
* Project \_\_\_
* Initiation
* Planning
* Execution
* Monitoring and Controlling
* Closing
61
PM Phase 1 - Project \_\_\_
* Define \_\_\_
* Create a \_\_\_
* Complete a project \_\_\_
* Draw up list of \_\_\_
Initiation
* Define goals
* Create a business case
* Complete the project charter
* Draw up the list of stakeholders
62
PM Phase 2 - Project \_\_\_
* Define \_\_\_
* Create a project \_\_\_
* Set a ___ baseline
* Define ___ and \_\_\_
Planning
* Define scope
* Create a project plan
* Set a budget baseline
* Define roles and responsibilities
63
PM Phase 3 - Project \_\_\_
* Allocate project \_\_\_
* Manage project \_\_\_
* ___ the product or process
* ___ often and fix issues as they arise
Execution
* Allocate project resources
* Manage project resources
* Build the product or process
* Meet often and fix issues as they arise
64
PM Phase 4 - Project \_\_\_
* Track ___ and \_\_\_
* Monitor project \_\_\_
* Ensure \_\_\_
* Prevent any chance for \_\_\_
Monitoring and Control
* Track effort and cost
* Monitor project progress
* Ensure adherence to plan
* Prevent any chance for disruptions
65
PM Phase 5 - Project \_\_\_
* ___ deliverables
* ___ project deliverables
* Get project results \_\_\_
* Document project \_\_\_
Completion
* Handover deliverables
* Review project deliverables
* Get project results approved
* Document project learnings
66
NANDA
North American Nursing Diagnosis Association
A working definition of nursing diagnosis was adopted by the **North American Nursing Diagnosis Association** (NANDA) Biennial Business Meeting in March 1990.
67
A suite of designated standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information and is also a required standard in interoperability specifications of the U.S. Healthcare Information Technology Standards Panel
SNOMED CT
68
An ___ is a record of healthcare information of an individual created and managed within one healthcare organization. An ___ is a record of healthcare information of an individual that conforms to recommended interoperability standards for ___ which is used across multiple healthcare organizations.
Meanwhile, a ___ is an electronic application through which patients can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment.
EMR, EHR
Standards for HIT (Health Information Technology)
PHR (Personal Health Record)
69
Meaningful Use incentives were imbibed into law in the \_\_\_
Health Information Technology for Economic and Clinical Health (HITECH) Act
70
The aim of the ___ incentive program is to improve the quality, efficiency, and coordination of patient care by leveraging certified EHR technologies securely and efficiently.
Meaningful Use
71
\_\_\_ enable unauthorized users to gain access to your computer without being detected
Rootkits
72
A ___ replicates itself by infecting other computers that are on the same network. They're designed to ___ and \_\_\_
Worm
consume bandwidth, interrupt networks
73
\_\_\_-based care refers to the payment a health care provider receives for services a patient might need. The type of service and quality of service does not really make a difference in the amount a provider might receive.
(Sometimes referred to as a ___ care)
Volume
fee-for-service
74
\_\_\_-based care is sometimes known as accountable care. This type of system focuses on getting value from quality services. Payments are based on this specialized care and other things, such as cost reduction, which could lead to an emphasis on ___ care.
Value, preventative
75
**\_\_\_** are computer-based programs that analyze data within EHRs to provide prompts and reminders to assist health care providers in implementing evidence-based clinical guidelines at the point of care. Applied to cardiovascular disease (CVD) prevention, for example, by reminding providers to screen for CVD risk factors, flagging cases of hypertension or hyperlipidemia, providing information on treatment protocols, prompting questions on medication adherence, and providing tailored recommendations for health behavior changes.
**Clinical decision support systems (CDSS)**
76
\_\_\_ telemedicine is "store-and-forward video-conferencing," which is the "transmission of a (pre-)recorded health history to a health practitioner, usually a specialist."
Asynchronous
77
While ___ refers specifically to remote clinical services, ___ can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical \_\_\_, in addition to clinical services.
telemedicine, telehealth
continuing medical education
78
This system is comprised of the hardware and software that make up an organization’s infrastructure.
Information Systems
The terms healthcare information system and hospital information system (HIS) both refer to a group of systems used within a hospital or enterprise that support and enhance healthcare.
79
This science, originally a sub-discipline of computer science, supports the collection and management of information and applies technology to make information usable.
Information Science
80
This nurse is expected to have fundamental information-management and computer-technology skills and use existing information systems and established information-management practices.
The Beginning Nurse
81
Known as the ability to read and understand the written word and numbers as well as the ability to recognize when information is needed.
Information Literacy
82
This initiative called for improving nursing education competencies for the development of a workforce capable of delivering patient care through health information technology
The Technology Informatics Guiding Education Reform Initiative (TIGER)
83
This system is integrated with other administrative and clinical systems and tracks a patient’s activities and locations from hospital or clinic
Admission/Discharge/Transfer (ADT) system
84
This interdisciplinary team is tasked with planning, testing, training, and other responsibilities when an EHRS has been purchased.
Implementation team or committee
85
The first standardized nursing terminology recognized by the ANA and used for nursing diagnosis
North American Nursing Diagnosis Association International (NANDA-I)
86
A collection of patient data controlled by the patient and accessible by patient and providers
Personal Health Record
87
The implementation of __________ terminology within the EHR is essential for healthcare organizations to meet the criteria of Meaningful Use
standardized
88
This is a globally recognized controlled healthcare vocabulary that provides a common language for electronic health applications to exchange data
Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT)
89
This is the primary reason nursing participation is essential on the implementation team
Knowledge of workflow/workflow analysis
90
This record provides a snapshot of a person’s current healthcare to a provider who does not have direct access to the EHR; intended to improve continuity and reduce errors
Continuity of Care Record (CCR)
91
This process that uses software to look for hidden patterns and relationships in large data sets
Data Mining
92
Unauthorized access to a server room is an example of this type of threat
Physical Threat
93
Any breach of confidentially within the healthcare environment is subject to the penalties of this act
Health Insurance Portability and Accountability Act (HIPAA)
94
This security measure protects the healthcare provider if they leave the computer abruptly
Automatic Sign-off
95
Software used for detecting security violations, performance problems, and flaws in applications by recording activity by users and systems
Audit Trails
96
This act authorized incentive payments for early EHR adopters and led to the development of Meaningful Use criteria
HITECH
Health Information Technology for Economic and Clinical Health
97
Type of environment that encourages reporting of errors or near misses, and focuses on systematic view of errors rather than individual causation
Blame-free environment
98
Defined as a vision to develop policies, funding, infrastructure, and education to instill knowledge and skills needed by all healthcare executives, clinicians, and informaticists, and the tools to gather and analyze amassed data
Culture of Informatics
99
Alerts, clinical pathways, order sets, dashboards, diagnostic support and drug-drug interaction tools are all examples of these
Decision-support software (DSS) or Clinical Decision Support Software (CDSS)
100
The phenomenon where too many insignificant CDSS warnings or recommendations are presented, and providers begin to dismiss them regardless of the importance
Alert fatigue
101
Since 2018, EHRs are required to demonstrate all the Core Requirements of Meaningful Use (MU). How many can you identify?
102
The use of telecommunication technologies and computers to provide healthcare information and services to clients at another location
Telehealth
103
Videoconferencing, Telestroke, Telepsychiatry, and Robotics belong in this category of services
Synchronous Connected Health Applications
104
Examples of this type of Telehealth include research/data mining, Grand Rounds, remote education, and expert consultation
Non-clinical Telehealth
105
Asynchronous telehealth application that can record and send photos, x-rays, and ECGs to a provider for evaluation
Store and Forward Technology
106
List at least 3 legal or business issues that must be considered prior to adoption of telehealth services by providers
* Privacy & informed consent
* Licensure Reimbursement
* Malpractice liability
* Online prescribing
* Credentialing
* Internet bandwidth
107
Skilled in using information management and computer technology; have strong analytic skills to learn from relationships between different data elements; and be able to collaborate with the informatics nurse specialist to suggest improvement to systems
Experienced Nurse
108
Analytics can be used to forecast the likelihood of \_\_\_
an event
109
\_\_\_ changes are small, ___ changes are larger in scale
Adaptive (new role, new computer/software system)
Transformational (new process/procedure, new department)
