HCS IINURSING INFORMATICS

By: Emerose C. Galves

CHAPTER 14

Electronic Health Record System

EHR – S

Is often used interchangeably with computerized patient record clinical information system, electronic medical – record, and many others. Yet the choice of the words in the term EHR – S reflects the boarder focus on the health of the consumer or patient and indicates that the EHR – S may be used by all participants in the process of achieving health, including all disiplins of clinical, family caregivers and the patient.

An EHR – S includes the following:

Longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or healthcare provided to an individual.

Immediate electronic access to person and population – level information by authorized, and only authorized, users.

Provision of knowledge and decision support that enhances the quality, safety, and efficiency of patient care.

Support of efficient process for healthcare delivery.

 Federal Initiatives

Different departments exert different influence towards the common goal of an EHR for most Americans. Other agencies provide leadership by offering monetary incentives; finding research, development and demonstration projects; and shaping regulations and policy.

Government as Provider and Early Adopter

The Veterans Health Administration in the Department of Veterans Affairs (VA) and the National Institutes of Health (NIH) in the Development of Health and Human Services (HHS) are two examples of the initiation of system in the 1970’s that were activity used by clinicians.

Department of Veterans Affairs

The Veterans Health Information System and Technology Architecture (VISTA) support day – to – day clinical and administrative operations at local VA healthcare facilities. All electronic records are password protected to guarantee patients privacy other features include the following:

A checking system that alerts clinicians if an order they are entering could cause a problem.

A notification system that immediately alerts clinicians to clinically significant events.

A visual posting system that alerts healthcare providers to issues specifically related to the patient on the opening of the patients electronic chart, including crisis notes, adverse reactions, and advance directives.

A template system that allows the healthcare provider to automatically create reports.

A clinical reminder systems that electronically alerts clinicians when certain actions, such as examinations, patien education, and laboratory test, need to be performed.

Remote data viewing to allow clinicians to see the patient medical history at all the VA facilities where the patient was seen.

Department of Defense

Within DoD, providers have had a computerized physician order entry capability that enables them to order lab test and radiology examinations and issue prescriptions electronically for over 10 years.

Indian Health Service

The IHS has long been pioneer in using computer technology to capture clinical and public health data. RPMS was developed in 1970 and many facilities have access to decades of personal health information and epidemiologic data local populations.

Government as Leader

The government is also pursuing the development of a public – private national health information network to facilitate EHR – S deployment.

Office of the National Coordinator for Health Information Technology

The executive order of April 2004, mentioned earlier in the chapter, created the ONCHIT to coordinate HIT efforts in the federal sector and to collaborate with the private sectors in driving HIT adoption across the healthcare system.

The National Committee on Vital and Health Statistics in 2000 and 2001, the National Committee on Vital and Health Statistic (NCVHS) which advises the secretary of HHS on health information policy, held a series of national hearings to develop a consensus vision of the national Health Information Infrastructure (NHCII).

*Goals of the Strategic Framework*

Goal 1

Inform Clinical Practice: Informing clinical practice

Is fundamental to improving care and making healthcare delivery more efficient. Three strategic for realizing goal are:

Incentivize EHR adoption Reduce risk of EHR investment Promote EHR diffusion in rural and

under segued areas

Goal 2

Interconnect Clinicians: will allow information to be portable and to more with consumer. The three strategies for realizing this goal are:

Foster regional collaboration Develop national health information

systems. Coordinate federal health

information systems.

Goal 3

Personalize care: consumer – centric information helps individuals manage their own wellness and assist with their personal healthcare decisions. The three strategies for realizing this goal are:

Encourage use of personal health records

Enhance informed consumer choice Promote use of telehealth systems

Goal 4

Improve Population Health: Requires the collection of timely, accurate, and detailed clinical information to allow for the evaluation of healthcare delivery and the reporting of critical findings to public health officials, clinical trials other research and feedback to clinicians:

Unify public health surveillance architecture Streamline quality and health status

monitoring Accelerate research and dissemination of

evidence

Agency for Healthcare Research and Quality

In addition AHRQ funded demonstration grants to establish and implement interoperable health information systems and data effectiveness of healthcare for patients and populations on a specific state or regional level.

Center for Medicare and Medicaid Services

Several large pilot programs were authorized in the 2003 Medicare Modernization Act (MMA) the 3 – year is intended to promote continuity of care, help stabilize medical conditions and reduce adverse health outcomes, such as adverse drug interactions.

Public Private Partnership

Among these private sector organizations are those formed specifically to address issues of connectivity, HIT, and standards development.

Connecting for Health

Is addressing the barriers to development of an interconnected health information infrastructure. It brings together several dozen of the leading healthcare provider and prayer organizations, HIT vendors and representatives of federal and state agencies.

eHealth Initiative

Is an independent, nonprofit affiliated organizations established to foster improvement in the quality safety, and efficiency of healthcare through information and IT. Shares its mission and providers funding for its initiatives.

Is Connecting Communities for better, a nearly $4miillion program that provides seed funding and technical support to multi stakeholder collaborative within communities that are using electronic health information exchange and other HIT tools to drive improvements in healthcare quality, safety and efficiency.

Institute of Medicine

As an independent adviser to the nation with the goal of improving health, the 10M has championed the advantages of use of IT to improve healthcare since its 1991 foundational work: the report created a framework for identifying core functions of an EHR – S, along with the primary and secondary uses of these systems.

Certifications Commission for Health Information Technology

The goal of this group is to support Goal 1, strategy 2, “Reduce risk of EHR investment” of the strategic framework. Twelve commissioners serve on the certification group, with two ex – officio representing the federal government.

Health Level Seven

- Is known for its large body of work in the production of technical specifications for the transfer of healthcare data. This transport mechanism known as messaging, is widely used domestically and internationally.

- The HL7 EHR –s functional model contains a list of functions in three categories: direct care, supportive, and information infrastructure.

Direct care functions are familiar to clinicians. Supportive functions involves secondary use of the

data captured via the direct care functions. Information infrastructure section is the “backend” of

the systems.Functional Model is the Creation of a Profile.

CHAPTER 15

Dependable System for Quality Care

Guidelines for dependable System

In this section we discuss five fundamental guidelines that can help increase the dependability of healthcare systems.

Guidelines 2: Anticipate Failures

The infrastructure level, features that are transparent to software applications should be implemented to detect faults are detected and to recover from failures before they become catastrophic. To handle exceptions in the execution of specific software applications, application – specific feature should be implemented security feature to detect, disable and recover from malicious attacks, while preserving system stability and security, should be implemented.

Guidelines 1: Architect for Dependability

Fundamental Principle of System architecture is that an enterprise system architecture should be developed from the bottom up so that no critical component is dependent on a component less trustworthy than itself. At the bottom of the architecture are the physical and logical networks that support the enterprise and provide the “pipes“ that carry data from system to system.

Guidelines 3: Anticipate Success

The system planning process should anticipate business success and the consequential need for larger networks more system, new applications, and additional integration. Such models can provide valuable input into planning for scalability and future integration.

Guidelines 4: Hire Meticulous Managers

Managing and keeping complex network and integrated system available and responsive requires meticulous overseers – individuals who know that failures will occur and accept that failures are most likely to occur when they are least expected.

Guidelines 5: Don’t be – Adventurous

Imagine that small start – up company called Cute Chutes has announced the availability of a new parachute unit that promises to revolutionize the sport of sky diving.

Assessing the Healthcare Industry

This system provides an informal assessment of how well healthcare provider organizations follow the guidelines discussed above.

Healthcare Architectures

Healthcare Organizations build – or perhaps “compose” their systems from the top down rather than from the bottom – up. The healthcare professionals select the user interfaces they like, and the IT team negotiates terms with the vendors who offer the systems that generate those interfaces these systems are familiarly known as “departmental” system because they generally are used only in one department, such as registration laboratory, or pharmacy.

The healthcare Portability and Accountability Act (HIPAA) security regulation prescribes administrative. Physical and technical safeguards for protecting the confidentially and integrity of health information and the availability of critical systems services.

Eight Required Administrative

Security management, including security analysis and risk management.

Assigned security responsibility. Information access management, including the isolation of

clearinghouse functions from clinical function. Security awareness and training. Security incident procedures, including response and

reporting. Contingency planning, including data back up planning

disaster recovery planning, and planning for emergency mode operation.

Evaluation. Business associate contracts that lock in the obligations of

business partners in protecting health information to which they may have access.

Five Specified Physical

Access control, including unique user identification and an emergency access procedure.

Audit control. Data integrity protection. Person or entity authentication. Transmission security.

Anticipating Success

Healthcare organization definitely expect their software applications, computer system, and networks to work.

Anticipating Failure

Medical technology and prescription drugs, as well as clinical treatment protocols, are required to undergo extensive validation before they can be used in clinical practice.

IT Management

These organization have hired IT manager who appreciate the important role of IT in a healthcare environment and who recognize the need for dependable systems that can anticipate and recover from failures.

NURSING MINIMUM DATA SET SYSTEM

Chapter 16

Includes three broad categories of elements

Nursing care Patient or client demographics Service Elements

The NMDS was develop by building on the foundation establish by the United State uniform hospital discharge.

Nursing Elements

Nursing diagnosis Nursing intervention Nursing outcomes Intensity of nursing care

The NMDS identifies essential, common and core data elements to be collected for all patients/client receiving nursing care.

Is a standard approach that facilitates that abstraction of these minimum, common, essential care data elements to describe nursing practice.

The NMDS was conceptualized through a small group work at the nursing information system (NISS) conference help in 1977 at the University of Illinois College of Nursing.

Patient or Client demographic elements

Personal identification Date of birth Sex Race and ethnicity Residence

Service elements

Unique facility or service agency number Unique health record number or

patient/client Unique number of principle registered

nurse provider Episode admission or encounter date Discharge or termination date Disposition of patient/client Expected payer for most of this bill

Standards and Research Era – Twenty – First Century

The NMDS influenced the work of the professional nurses association. In 1991, the Americans Nurses Association (ANA) recognized the NMDS as the minimum data elements to be included in any data set or patient record.

The NMDS servers as a key component of the standards developed by the Nursing Information and Data Set Evaluation Center (NIDSEC).

NIDSEC develops and disseminates standards related to nomenclature, clinical associations, clinical data repositories, and system characteristics/ decision support/contextual variable pertaining to data sets in information system that supports the documentation of nursing practice (NMDS).

National Nursing Minimum Data Sets

Establish NMDS’s

The Early NMDS work in the United States spurred the development of NMDS in numerous other countries. A perusal of these data set reveals a definite consensus on the importance of the nursing care elements across all countries which identified NMDS’s.

Emergent NMDS’s

Several countries across most continents beyond North America are exploring development of NMDS systems.

It is clear that there is major work being accomplished across the globe to ensure that nursing essential data will be more comprehensively available in the future.

NMDSs relationship to International Nursing Minimum Data Set (I – NMDS).

Evolution of Concept

The i – NMDS includes the core, internationally relevant, essential, minimum data elements to be collected in the course for providing nursing care.

These data can provide information to describe compare and examine nursing practice around the globe.

i-NMDS is intended to build on the efforts already underway in individual countries.

Cosponsor ship

The i-NMDS Research Center is lead by a steering committee of international representative of countries with existing and emerging NMDS as well as professional cosponsor ship and areas of informatics expertise.

Purposes

Describing the human phenomena Improving the performance of

healthcare system Enhancing the capacity of nursing Addressing the nursing shortage Testing credence based practiced

improvements Empowering the public

internationally

Data Elements

The i-NMDS elements are organized into three categories, subjects of care, and nursing elements.

Future Directions

The power of NMDS to describe nursing practice from international perspective is daunting.

THEORIES, MODELS AND FRAMEWORK

Chapter 17

Foundational Documents Guide Nursing Informatics Practice

In 2001, the American Nurses Association (ANA) published the code of Ethics for nurses with Interpretive statements, a complete prevision and interpretive statements that guide all nurses in practice, be it in the domain of direct patient care, education, administration, or research.

Nursing informatics is the nursing specialty that endeavors to make the collection, and knowledge easier for the practitioner, regardless of the domain and setting.

Informatics and Healthcare Informatics

Informatics is a science that combines a domain science, computer science, information science, and cognitive science.

Healthcare informatics may be defined as the integration of healthcare information.

Healthcare informatics address the study of management of healthcare information.

Nursing informatics reflects this duality as well, moving in and out of integration and separation as situations and needs demand.

Nursing Informatics

In 1985, Kathryn Hannah proposed a definition that nursing informatics in the use of informatics technologies in relation to any nursing function and action of nurses.

Nursing sciences, computer science and information, and knowledge to manage and communicate data, information, and knowledge in nursing practice.

Nursing informatics as a Specialty

In early 1992, the ANA established nursing informatics as a destine specialty in nursing with a distinct body of knowledge.

The scope of nursing informatics practice includes activities such as developing and evaluating applications, tools, processes, and strategies that assist registered nurses in managing data to support decision – making.

Models for Nursing Informatics

Models are representation of some aspect of the real world. Models show particular perspectives of a selected aspect and any illustrate relationships. Models evolve as knowledge about the selected aspect changes and are dependent on the “world view” of these developing the model.

Data Information and Knowledge

Data, information and knowledge are defined as current met structures or overarching concepts for nursing informatics with specific definitions in the scope and standards of Nursing Informatics Practice. Data are “discrete entities that are described objectively without interpretation” and would include some value assigned to a variable.

Registered Nurses as Knowledge Workers

Knowledge worker is the exercise of specialist knowledge and competencies.

Knowledge and Competencies Registered nurses are consumable

twenty first century knowledge workers.

Knowledge work of course, depends on access to data, information and knowledge.

Competencies

This desired change in skills involves the evolution from novice level to advanced beginner to competent to proficient to finally an expert level.

Electronic Health Record

Healthcare environment is characterized by significant emphasis on establishing the EHR in all settings.

The concept of EHR emerged, initially, as a computer – based patient record or CPR and was given significant impetus ba a 1991 report from the institute of medicine that advocate the adoption of the CPR as the primary source of client healthcare data and information.

Terminologies

This is best accomplished by using standard communication formats and terminologies and recognized convention for describing the concepts being presented. Concept representation involves the set of terms and relationship that describe the phenomena, processes, and practices of a discipline, such as nursing.

NANDA

Has evolved from alphabetical listing in the mid – 1980’s to a conceptual system that guides the classification of nursing diagnoses in a taxonomy and includes definitions and defining characteristics.

Includes 167 recognized diagnoses that every different from the pathology and mortality focus of the ICD – 9 CM terms used for medicine and third party payment claims.

Nursing Interventions Classification (NIC)

The fourth edition of NIC contains 514 nursing interventions that describe the treatments nurses perform updated linkages with NANDA diagnoses and core interventions identified for 44 specialty practice areas. There terms differ from the surgically biased CPT – 4 code set terms used by medicine and third party programs.

Nursing Outcome Classification (NOC)

To provide standardization of expected patient, caregiver, family and community outcomes for measuring the effect of nursing interventions.

Clinical Care Classification (CCC) Formerly Home Health Care Classification (HHCC)

CCC system is a research – based nomenclature designed to standardize the terminologies for documenting nursing care in all clinical care settings.

Ohama System

Was released in November 2004, originally developed for use un home practice, the Ohama system is now used in all clinical settings.

SNOMED CT

Is a core clinical terminology containing over 357,000 healthcare concepts with unique meanings and formal logic – based definitions organized into multiple hierarchies.

Perioperative Nursing Data Set (PNDS)

The PNDS provides a universal language for peri – operative nursing and education and a framework to standardize documents.

ABC Codes

Provide a mechanism for coding integrative health interventions by clinician by state location for administrative billing and insurance claims.

Patient Care Data Set (PCDS)

Includes terms and codes for patient problems, therapeutic goals, and patient care orders. This data set was developed by Dr. Judith Ozbolt from research data from nine acute care hospitals throughout the United State.

Logical Observation Identifiers Name and Codes (LOINC)

Originated as a database of standardized laboratory term for result reporting for chemistry, hematology, serology, microbiology, and toxicology.

Includes about 32,000 terms including a clinical portion with codes for observations at key stages of the nursing process, including assessments, goals and outcomes.

International Classification for Nursing Practice (ICNP)

Is a combinational terminologies for nursing practice developed by the international nursing community under sponsorship of the International council of Nurses (ICN).

Nursing Management Minimum Data (NMMD)

Includes terms to describe the context and environment of nursing practice, and includes terms for nursing delivery unit/service, patient/client population, care delivery method, personnel characteristics and financial resources.

Organization as Resources

Provide information resources and value – added membership benefits that support those individuals interested in healthcare and nursing informatics.