Information Technology in Nursing
Terms in this set (89)
Public Health Informatics
application of information, computer science, and technology to public health practice, research and learning
Electronic Patient Record (EPR)
Another name for an electronic health record; an individual's health information kept in a computer system for the current episode of care. Not necessarily a lifetime record.
"Addresses the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work"
Software that allows users with little to no programming experience to create instructional computer programs
Logical Observation Identifiers Names and Codes
A clinical vocabulary including terms used in the electronic exchange of laboratory results and clinical observations
Electronic Medical Record (EMR)
Patient medical record from a single medical practice, hospital, or pharmacy. The source of data for the Electronic Health Record (EHR).
Electronic Health Record (EHR)
a computerized lifelong healthcare record for an individual that incorporates data from all providers who treat the individual
Guiding Education Reform
promotes nursing knowledge and skill needed to practice in a technology driven environment
SNOMED-CT (Systematized Nomenclature of Medicine Clinical Terms)
Classification System that includes signs and symptoms of dieseas, diagnoses and procedures for the integration of all medical information in the Electronic Medical Record.
"Standard language" for use in medical records.
Regional Health Information Organization (RHIO)
group of health care organizations that share information.
Picture Archiving and Communication System (PACS)
Database that stores radiologic images and allows physicians remote access to those images.
Nursing Outcomes Classification (NOC)
A classification system that defines and describes patient outcomes to nursing interventions.
Nursing Interventions Classification (NIC)
A listing of research-based nursing intervention labels that provides standardization of expected nursing interventions.
Quality Data Codes (QDC or G-Codes)
A special set of non-payable HCPS Codes for measurement of the quality of care physicians give to their patients.
personal health record (PHR)
An electronic record of health-related information about an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources but that is managed, shared, and controlled by the individual. A lifelong record.
Nursing Minimum Data Set (NMDS)
A data set that provides uniform definitions and categories of nursing care; built on the uniform minimum health data sets (UMHDS)
clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences
Use of computer artificial intelligence to arrive at a decision that experts in the field would make. Clinical decision making system.
study of whole genomes, including genes and their functions for the purpose of providing individualized treatments.
Healthcare Information Exchange
The electronic sharing of patient information (i.e. demographics, allergies, chief complaint, etc.) between providers according to nationalized standards.
Healthcare Information System
Computer hardware & software dedicated to the collection, storage, processing, retrieval and communication of patient care information in a healthcare organization.
HIPAA (Health Insurance Portability and Accountability Act)
a.k.a. the Kennedy-Kassebaum Bill
First federal legislation to protect automatic client records and also mandated that all electrionic transactions include only HIPAA compliant codes.
Health Level 7 (HL7)
An international organization of healthcare professionals dedicated to creating standards for the exchange, management, and integration of electronic information
HITECH Act of 2009
-Incentives to providers for adopting meaningful use of EHR technology
-Meaningful use: criteria in quality, safety, efficiency, etc.
-Portion of ARRA
Hospital Information Systems
A group of information systems used within a hospital or enterprise that support and enhance patient care.
-Consists of two types of information systems
-Clinical and Administrative
the science and art of turning data into information
an RN with experience but no formal education in the area
Informatics Nurse Specialist
An RN with formal, graduate level education in the field of informatics or a related field and is considered a specialist in the field of nursing informatics.
the right to determine when, and to what extent, information about you can be gathered and/or communicated to others.
ex. informed consent to release medical records
ICD-9 and ICD-10
International Classification of Disease-standard developed by World Health Organization (WHO) contains diagnosis codes that are used in all health care settings.
The International Classification of Nursing Practice is a classification used to describe clinical nursing practices across all settings.
Skills, experience, and expertise coupled with information and intelligence that creates a person's intellectual resources
Knowledge Discovery in Databases (KDD)
a machine-learning process that performs rule induction or a related procedure to establish knowledge from large databases. a.k.a. data mining
refers to the creation of systems that enable organizations to tap into the knowledge, experiences and creativity of its staff to improve their performance
a structured process for the generation, storage, distrubution and application of personal experience along with knowledge evidence in organizations
Laboratory information system (LIS)
An information system that collects , stores, and manages laboratory tests and their respective results. The LIS can speed up access to test results through improved effciency from various locations, including anywhere in the hospital, the physician's office, or even the clincian's home.
Master Patient Index (MPI)
A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death
the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid
the use of computers and computer technology in health care and its delivery
Medical Severity DRG
This was implemented by CMS in 2007 to classify inpatient hospital cases into groups according to similar resource utilization.
North American Nursing Diagnosis Association organized in 1973. It formally identifies, develops, and classifies nursing diagnoses.
NHIN (National Health Information Network)
key component of government HIT strategy that will provide a common platform for health information exchange across the country
specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
Nursing Information System
Supports the use and documentation of nursing activities and provides tools for managing the delivery of nursing care
Digital Image Communication in Medicine (DICOM)
Standard that promotes the communication, storage & integration of digital images with hospital information systems.
Decision Support System (DSS)
an interactive, flexible, computerized information system that enables managers to obtain and manipulate information as they are making decisions
the process of analyzing data to extract information not offered by the raw data alone
Current Procedural Terminology (CPT)
the standardized classification system for reporting medical procedures and services
multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
Continuity of Care Document (CCD)
A document that conforms to a standard, accepted format for electronically transmitting/sharing patient information securely in a format that is easy to read and share among provider locations
the process of ensuring the continuation of critical business services regardless of any event that may occur.
Computer based patient record
Automated patient record desiged to enhance and support patient care through availability of complete and accurate data as well as bodies of knowledge and other aids to care providers.
Computer Based Patient Record System
People, data, rules, procedures and computer and communication equipment and facilities that procide the mechanism by which patient records are created, used, stored and retrieved.
Branch of nurmetrics. Uses models and simulation for the application of existing theory and numerical methods to new solutions for nursing problems, or the development of new computational methods
Community Health Information Network (CHIN)
"An integrated collection of computer and telecommunications capabilities that facilitates communications of patient, clinical, and payment information among multiple providers, payers, employers, and related healthcare entities within a community"
a disaster recovery option that relies on access to an alternative facility that is prewired for necessary telephone and internet access, but does not contain any computing equipment
A technique used to evaluate a computer interface or a software program by breaking down and explaining the steps that a user will take to accomplish a task.
Clinical Information Systems
large, computerized database management systems that support several types of activities that may include provider order entry, result retrieval, documentation, and decision support across distributed locations
Clinical data repository (CDR)
a special database that manages healthcare data from different sources such as labs, pharmacies, and radiology networks
Clinical Information Analyst
One who synthesizes data and interprets its relationship to clinical interventions
Clinical Care Classification (CCC)
a classification system of nursing diagnoses and interventions organized under 21 care components to support documentation of the nursing process
Uses mutually exclusive categories for specific purposes such as describing the details of a patient encounter for clinical, administrative or reimbursement purposes.
Bibliography Database Manager (BDM)
Allows importation of references directly from databases
A process of continuously measuring system results, comparing those results to optimal system performance (benchmark values), and identifying steps and procedures to improve system performance
BCMA (Bar Code Medication Administration)
A system designed to prevent medication errors in healthcare settings. Is used by nurses in healthcare settings who are administering medications
Information that is preloaded into the system before the go-live date.
Asynchronous Transfer Mode (ATM)
high speed data transmission method suitable for voice, data, image, text and video information that use fiber or twisted pair cable. Faster than ISDN. Used less frequently d/t high cost.
ARPANET (Advanced Research Projects Agency Network)
Precursor of today's internet - funded by D.O.D.
A standard language for encoding medical knowledge representation for use in clinical decision support systems
reusable clinical models of content & processes significant for an initiative to develop a lifelong electronic record
American Recovery and Reinvestment Act (ARRA)
Legislation that includes provisions for Health Information Technology and funding for the Office fo the National Coordinator of Health Information Technology (ONCHIT)
Ambulatory Payment Classification (APC)
Prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required.
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
Administrative Information Systems
support client care by managing financial and demographic information and providing reporting capabilities
Accountable Care Organization (ACO)
Payment and healthcare delivery reform model that ties provider reimbursement to quality metrics and reductions in the total cost of care for a given patient population
Facts and statistics collected together for reference or analysis
Data converted into a meaningful and useful context
synthesis of information from several sources to produce a single concept
Information Technology (IT)
the computers and other electronic devices used to store, retrieve, transmit and manipulate data
collects, processes, stores, analyzes, and disseminates information for a specific purpose
Focus on how to gather, process and transform information into knowledge. It also incorporates features from 5 other sciences
employees whose main contribution to the organization is specialized knowledge, such as knowledge of customers, a process, or a profession
work that is primarily concerned with information rather than manual labor
nurse collects clinical data such as vital signs
interprets clinical data and uses it to monitor patients, aids with decisions
Nurses display this role when they aggregate clinical data and show patterns across patients that serve to create new knowledge or can be interpreted within the context of existing nursing knowledge.
How does IT influence nursing roles?
Strengthens clinical databases
Device integration - ex. information being fed directly into the EHR such as lab test results or point of care testing
Has basic computer skills
Uses information systems to manage patients.
Access data and charts electronically
Supports patient safety initiatives using IT
Recognizes the role of informatics in nursing
- Possess basic computer skills.
- Supports improvement of quality through IT.
- Use evidence based databases.
- Promote technology applications.
- Promote system improvements in conjunction with IT staff.
- Proficient with informatics applications.
- Fiscal management.
- Integration of multidisciplinary language of practice.
- Demonstrates critical thinking, decision-making, and system development.
- Helps in decision making.
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