DIVINE WORD COLLEGE OF LAOAG SCHOOL OF NURSING NURSING INFORMATICS ISSUES IN INFORMATICS Nursing Informatics and Healthcare Policy

as a Specialty -in 1992, American Nurses Association (ANA) recognized NI as a specialty -NI first appeared in the literature in 1980’s and has constantly evolved and molded by maturation of the field and influenced by health policy. -NI is the combination of nursing, information and computer sciences to manage and process nursing data into information and knowledge for use in nursing practice (Graves and Corcoran, 1989). -NI is a specialty that integrates nursing science, computer science and information science to manage and communicate data, information and knowledge in nursing practice. - NI facilitates the integration of data information and knowledge to support patients, nurses and other providers in their decision making in all roles and settings. NI Differentiated Interdisciplinary Practice: -An informatics nurse demonstrates specialized knowledge of information and technology. -Informatics nurses should assist with the development and implementation of technology tools for clinical practice, evaluation of the effectiveness of the technological tools on nurses works and help prepare nurses to use information technologies. -NI differentiates itself from other areas of nursing practice but emphasizes its interaction with informatics disciplines such as math, statistics, linguistics, engineering, computer science and health informatics. -NI is a specific domain of informatics that falls under a broader umbrella of health informatics (others are medical informatics, dental informatics and consumer informatics) -NI community believes it is essential to practice within an interdisciplinary team. (ex. Annual Vocabulary Summit in Vanderbilt University-that brings together nursing and medical informatics vocabulary experts to explore how further language development in nursing can facilitate the integration of computerized languages among healthcare disciplines) Preparation for Specialty Practice • Educational Programs

-the Division of Nursing (DN), Health and Human Services Administration (HRSA)funded two Master’s NI programs, University of Maryland and University of Utah and one doctoral program in NI at University of Maryland in 1988-1992. -In 1992, the American Nurses Association (ANA) officially established the role of the informatics nurse specialist, shortly after which they began offering the first credentialing exam in 1995. Although this recognition of NI is fairly new among the nursing specialty practices, skilled information management has always been a cornerstone of successful nursing practice. Nurses spend a significant portion of their time collecting and translating data for consumption by other providers, patients, and families. As computers increasingly become a tool for repositing healthcare information, it’s imperative that all nurses have computer competencies, just as they would with any other healthcare instrument. The ANA’s Scope and Standards of Nursing Informatics Practice (2001) identifies three progressive levels of NI competencies: the beginning nurse, experienced nurse, and informatics nurse specialist. As the specialty of NI has become more defined, nurses have sought out more learning opportunities and have benefited from the emergence of more formal NI education programs. Until the last decade, there were few formal NI programs. It’s even more recent that informatics theories and competencies have started being incorporated into basic nursing associate degree and baccalaureate curriculums. Not surprisingly, many practicing nurse informaticists received their “formal” training on the job, typically as a necessity of their institution’s systems implementation. -in 1997, NI specialty program opened in New York University and in 1998 at Duquesne University in Pittsburgh.

-the certification examination for NI graduates currently available is through the American Nurses Credentialing Center. - The American Nursing Credentialing Center (ANCC) began administering an informatics nurse certification exam in November 1995. The exam topics cover areas of basic IT, information and knowledge management, system development, human factors and NI models, theories, and professional practice. The ANCC details the nursing candidate’s qualifications for the informatics nurse certification exam as: • • • • • • a baccalaureate or higher an active RN license, with at least 2 years of professional practice practice of at least 2,000 hours of NI within the last 3 years OR 12 hours of graduate work and 1,000 hours of NI practice OR Completion of a graduate program in NI that included at least 200 hours of clinical practicum Completion of 30 continuing education contact hours in specialty area within the last 3 years for those who haven’t completed a graduate informatics program.

Those RNs, with a baccalaureate or higher degree in the field of nursing, who successfully pass the certification exam are recognized as “board certified” with the initials “RN,BC.” For RNs with baccalaureate or higher degree in a nonnursing field, their certification is recognized as “certified” with an “RN,C.” -a final requirement for a specialty in representation by at least one organization as NI has the support of both nursing and multidisciplinary organizations. (ex. American Medical Informatics Association (AMIA) and Health Information Management Systems Society(HIMSS)) Healthcare Policy Impact on Nursing Informatics Practice • Patient Safety

-In 2004, President G.W. Bush issued an executive order creating The Decade of Health Information Technology with a goal of establishing an electronic health record (EHR) for every American in the next 10 years. One of the reasons for this order was the release of findings from the Institute of Medicine (IOM) studies concluding that information technologies hold the promise to transform health care practice and facilitate patient safety -One of Centers for Medicare and Medicaid Services (CMS) most important initiatives is to assist practitioners in making care more effective and less costly, particularly by promoting adoption of health information technology -the Technology Informatics Guiding Educational Reform (TIGER) Summit in 2006 collaborated with colleagues from key federal agencies and healthcare organizations and articulated a vision for the future of nursing that enables nurses to use informatics in practice and education to provide safe, quality care. NATIONAL INFORMATICS INITIATIVES -The presidential initiative to provide an electronic health record to all Americans by 2014. As a member of the American Health Information Community (AHIC), associations identify actions needed to advance standards for electronic health data exchange. AHIC operates under the guidance of the Department of Health and Human Services. -The Nationwide Health Information Network works to build a secure, nationwide health information infrastructure to connect health providers, consumers and others supporting health and healthcare. AHIC workgroups establish guidance for development of the Network’s architecture. The Network aims to: • Give consumers more control of their health information • Provide better information for clinical decision making • Promote appropriate use of healthcare information beyond direct patient care ONC (Office of the National Coordinator for Health Information Technology) The Office of the National Coordinator for Health Information Technology (ONC) is at the forefront of the administration’s health IT efforts and is a resource to the entire health system to support the adoption of health information technology and the promotion of nationwide health information

exchange to improve health care. ONC is organizationally located within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS). ONC is the principal Federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. The position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009. Health IT Policy Committee The American Recovery and Reinvestment Act of 2009 (ARRA) provided for the creation of an HIT Policy Committee under the auspices of the Federal Advisory Committee Act (FACA). The HIT Policy Committee is charged with making recommendations to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information. Later that year, the HIT Policy Committee formed several workgroups to further the work of the FACA Committee. These workgroups are comprised of stakeholder representatives and subject matter experts. The HIT Policy Committee’s workgroups are: Meaningful Use Workgroup, Certification/Adoption Workgroup, Information Exchange Workgroup, NHIN Workgroup, Strategic Planning Workgroup, Privacy & Security Policy Workgroup, and Enrollment Workgroup. Health IT Standards Committee The American Recovery and Reinvestment Act of 2009 (ARRA) also provided for the creation of an HIT Standards Committee under the auspices of the FACA. The HIT Standards Committee is charged with making recommendations to the National Coordinator on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information. Initially, the HIT Standards Committee will focus on the policies developed by the Health IT Policy Committee. The HIT Standards Committee also formed several workgroups to further the work of the FACA. These workgroups are comprised of stakeholder representatives and subject matter experts. The HIT Standards Committee’s workgroups are: Clinical Operations Workgroup, Clinical Quality Workgroup, Privacy & Security Workgroup, and Implementation Workgroup. FHA (Federal Health Architecture) The Federal Health Architecture Initiative (FHA) represents a unique opportunity to build partnerships across communities of interest throughout the nation's health care environment in the development of a truly integrated and effective health information exchange network. FHA will enable the employment or migration of existing systems to meet citizen-centric business activities while providing clear rules for the development of new tools for improved performance and access to health related information and services throughout the national health arena. Participants other than the Department of Health and Human Services include Department of Homeland Security, Veterans Administration, Environmental Protection Agency, Department of Agriculture, Department of Defense, and Department of Energy. NCVHS (National Committee on Vital and Health Statistics) The NCVHS serves as the statutory [42 U.S.C. 242k(k)] public advisory body to the Secretary of the Department of Health and Human Services in the area of health data and statistics. In that capacity, the Committee provides advice and assistance to the Department and serves as a forum for interaction with interested private sector groups on a variety of key health data issues. The Committee is composed of 18 individuals from the private sector who have distinguished themselves in the fields of health statistics, electronic interchange of healthcare information, privacy and security of electronic information, population-based public health, purchasing or financing healthcare services, integrated computerized health information systems, health services research, consumer interests in health information, health data standards, epidemiology, and the provision of health services. Sixteen of the members are appointed by the Secretary of DHHS for terms of four years each, with about four new members being appointed each year. Two additional members are selected by Congress. AHRQ (Agency for Healthcare Research and Quality) The health services research arm of the U.S. Department of Health and Human Services (HHS), complementing the biomedical research mission of its sister agency, the National Institutes of Health.

Home to research centers that specialize in major areas of health care research:

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Quality improvement and patient safety. Outcomes and effectiveness of care. Clinical practice and technology assessment. Health care organization and delivery systems. Primary care (including preventive services). Health care costs and sources of payment.

A major source of funding and technical assistance for health services research and research training at leading U.S. universities and other institutions. A science partner, working with the public and private sectors to build the knowledge base for what works—and does not work—in health and health care and to translate this knowledge into everyday practice and policymaking. National Governors Association – State Alliance for e-Health Work to improve the nation's health care system and enable states to increase the efficiency and effectiveness of health information technology (HIT), the NGA Center formed a collaborative body known as the State Alliance for e-Health (State Alliance). The State Alliance provides a nationwide forum through which stakeholders can work together to identify inter- and intrastate-based health information technology policies and best practices and explore solutions to programmatic and legal issues related to the exchange of health information. The State Alliance is co-chaired by Vermont Gov. Jim Douglas and Tennessee Gov. Phil Bredesen who guide the efforts of governors, state legislators, attorneys general, insurance commissioners and others to help them develop real-world solutions and model practices for improving the quality and efficiency of health care. Interest Groups PEHRC (Physicians’ Electronic Health Record Coalition) In July 2004, 14 preeminent medical organizations, representing more than 500,000 U.S. physicians, announced the creation of the Physicians' Electronic Health Record Coalition (PEHRC). This groundbreaking health care coalition will assist physicians, particularly those in small- and mediumsized ambulatory care medical practice, to acquire and use affordable, standards-based electronic health records and other health information technology to improve quality, enhance patient safety, and increase efficiency. The coalition is committed to taking practical steps to educate physicians about the value and best use of electronic health records (EHR), and to assist them in selection of systems, as well as to help focus the market on high-quality and affordable products. eHealth Initiative (eHI) The eHealth Initiative and the Foundation for eHealth Initiative are independent, non-profit affiliated organizations whose missions are the same: to drive improvement in the quality, safety, and efficiency of healthcare through information and information technology. Both organizations are focused on engaging multiple and diverse stakeholders--including hospitals and other healthcare organizations, clinician groups, consumer and patient groups, employers and purchasers, health plans, healthcare information technology organizations, manufacturers, public health agencies, academic and research institutions, and public sector stakeholders--to define and then implement specific actions that will address the quality, safety and efficiency challenges of healthcare system through the use of interoperable information technology. The vision is that consumers, health care providers, and those responsible for population health will have ready access to timely, relevant, reliable and secure information and services through an interconnected, electronic health information infrastructure to support better health and healthcare. Connecting for Health – Markle Connecting for Health is a public-private collaborative designed to address the barriers to development of an interconnected health information infrastructure. The ability to deliver medical information where and when it is needed in a private and secure manner will help to improve the quality of care, reduce medical errors, lower costs and empower patients. The first phase of the Collaborative's work drove consensus on the adoption of an initial set of data standards, developed case studies on privacy and security, and helped define the electronic personal

health record (PHR). Connecting for Health is currently working to develop an incremental Roadmap intended to lay out near-term actions necessary to achieving electronic connectivity. To carry out its work, Connecting for Health has organized several working groups focusing on understanding the business and organizational issues of community-based information exchange, the issues relevant to sharing electronic information with patients, and several aspects of technical interoperability. Connecting for Health was established by the Markle Foundation and receives additional funding and support from the Robert Wood Johnson Foundation. HIMSS (Healthcare Information and Management Systems Society) HIMSS is exclusively focused on providing leadership for the optimal use of healthcare information technology and management systems for the betterment of human health. HIMSS represents more than 13,000 individual members and some 150 member Health I.T. corporations that employ more than 1 million people. HIMSS shapes and directs healthcare public policy and industry practices through its advocacy, educational and professional development initiatives, which are designed to promote information and management systems' contributions to quality patient care. HIMSS EHR Association (EHRA) The EHR Association is comprised of industry experts in the field of healthcare information technology with a broad scope of expertise such as medical and clinical informaticists, physicians, nurses, pharmacists, and technology experts who not only represent the EHR software industry but also interact and represent the entire healthcare community. The EHR Association offers unmatched experience and expertise, and provides a forum and structure for EHR leaders to work toward standards development, interoperability, the EHR certification process, performance and quality measures, HIT legislation, and other EHR issues. The association is a partner of the Healthcare Information and Management Systems Society (HIMSS) and operates as an independent organizational unit within HIMSS for companies who are EHR software solution providers. The EHR Association helps HIMSS establish its strategic direction and official positions on issues related to the electronic health record. AHIMA (American Health Information Management Association) The American Health Information Management Association is a community of professionals engaged in the field of health information management. AHIMA provides support to members and works to strengthen the industry and profession. It represents more than 45,000 specially educated health information management professionals who work throughout the healthcare industry. Health information management professionals serve the healthcare industry and the public by managing, analyzing, and utilizing data vital for patient care and working to make this information accessible to healthcare providers when it is needed most. AMIA (American Medical Informatics) The American Medical Informatics Association is the leading academic/scholarly organization in the United States dedicated to the research, development, and application of medical informatics in the support of patient care, teaching, research, and healthcare administration. AMIA intends to be, for medical informatics, what the ACP is for internal medicine. AMIA's individual members are physicians, nurses, dentists, biomedical engineers, medical librarians, researchers, scientists, educators, students and other healthcare professionals who have a strong interest in medical informatics. The Journal of the American Medical Informatics Association (JAMIA) is the premier U.S. journal in the field, and the AMIA annual meeting is the primary academic gathering for the specialty. Recently, AMIA has become active in public policy issues that have informatics components. TELEHEALTH TECHNOLOGIES • Clinical telehealth applications enable healthcare professionals to have face to face meetings with patients. They can see images and hear patient output as it is occurring or at a later time. (For example, telehealth applications enable clinicians to send and listen to a patient's captured heart and lung sounds) These applications allow professionals to view, send, or store video and digital images for a patient assessment, diagnosis, treatment, and evaluation over video conferencing technology and computer applications. This process can be especially helpful for health facilities with limited nursing resources, such as, health clinics, schools, prisons, or rural hospitals. In the homecare environment, telehomecare technologies assist home care nurses to monitor a patient's vital signs, including heart and lung sounds.

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These applications also enable a nurse, who is in a remote location relative to the patient, to identify changing trends in the patient's physiological state. This type of technology can also assist with medication compliance and decrease the need for in-home care or office visits. It can be of great value to patients in remote locations. It can help nurses in their everyday practice and provide them with an expanded set of career choices. It makes it possible to share medical skills, information, and know how It can provide nurses -- be they novices, experts, or somewhere in-between -- the opportunity to play an important role in the development, deployment, and utilization of telemedicine and telehealth applications in patient care. It allows clinicians to conduct remote physical assessment and consults, as well as capture and store patient information (with a store-and-forward software application) for further evaluation and sharing with a consulting physician or nurse practitioner. TELEHEALTH TECHNOLOGY

Six areas that are important to master in clinical telemedicine:

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Learning how to use the telemedicine medical devices as well as audio, video, and digital software applications over phone, Integrated Services Digital Network (ISDN), or Internet Provider (IP) communication networks Becoming techno-savvy in using other software applications for entering patient demographic data, saving, sending, and retrieving information to or from the consulting physician or nurse practitioner Collaborating with information technology staff, biomedical engineers, and telehealth physicians and nurses in one's health care system or hospital as a telemedicine/telehealth/ehealth team Assisting in the development of telehealth guidelines, policies, and procedures Reviewing and understanding the applicable Health Insurance Portability and Accountability Act (HIPAA) laws with use of telehealth applications Learning the evolution of telehealth/telemedicine/e-health technologies and how they are being used in healthcare

The eLearning A Learning Management System (LMS) to automate the processes associated with learning management administration, educational content development and program delivery provides a centralized, web-based portal for registration, course and curriculum management, student transcripts, testing, as well as activity tracking and reporting. The benefits of eLearning to staff:

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24/7 “just in time” access to educational information Increased number and variety of educational offerings Improved ability to track individual course registrations and/or course completion Reduced scheduling restrictions associated with classroom training

eLearning Centre To ensure that nurses across have access to the latest information when and where they need it, nurses can participate in online learning through the eLearning Centre. Nurses simply log in to the Centre (on the Intranet) and, with a few clicks of the mouse they can launch a course, review policies and confirm that they understand the content, take a quiz or register for an instructor led class. Some of the online courses that are currently available include:

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Diabetes Management Wound Care Venipuncture Focus Charting Pain Management Blood Transfusion Safety

Telenursing Nurses are using Telehealth technology to provide patient-centered care, during consultations with patients and other health professionals. The Telehealth Program uses videoconferencing to increase access to care for patients and to facilitate continuing education for health care professionals. For patients, this often represents a reduction in the expense, travel and wait time required for a new consultation or follow-up visit. Furthermore, videoconferencing enhances nurses opportunity to provide ongoing clinical and educational support to both patients and their local care providers. Telehealth technology has also been used to connect patients and families for compassionate reasons. Telenursing is the branch of telehealth that involves actual nursing and client interaction through the medium of information technology. While engaging with the virtual representation of a client, the nurse must strive to envision and experience the client's three dimensional body and being in order to accurately advise, assess, diagnose, and interact fully and dynamically. This perceiving must occur within the virtual network environment, where both body-sense and body-awareness are combined with digital information. Not only the body, but also the person's inner being must be acknowledged and somehow included. THE ROLE OF TECHNOLOGY IN THE MEDICATION USE PROCESS Influences on the adoption of technology Computerized provider order entry (CPOE), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at point-

of-care or off-site, provides error-checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges. Although manufacturers use the term Computerized Physician Order Entry, a more accurate term would be Computerized Prescriber Order Entry or Computerized Pharmacist Order Entry. Order Entry is in the domain of the pharmacist because it is the pharmacist's responsibility to verify any entry into the system concerning the use of medications within the hospital or health care system. Order clarification requests will be enhanced by improved communication and collaboration amongst the health care team.

BAR-CODE ENABLED POINT OF CARE- Barcode scanning and wireless mobility technologies at point-of-care improve patient safety by greatly reducing the possibility of human error.

Medication Administration Wireless mobile computers equipped with barcode scanners enable healthcare professionals to scan the patient wristband and the medication to verify the five “rights” -- the right medication is going to the right patient at the right time at the right dose using the right method of administration. Key benefits:

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Reduces the likelihood of dangerous errors due to medication mix-ups. Provides an immediate method of positive patient identification. Gives healthcare providers real-time access to patient data at the bedside. More opportunities for quality patient interactions and care. Specimen Collection True positive specimen identification begins at the point of collection. Whether its blood, tissue, or fluids, accurate test results and speedy diagnoses depend on specimens being clearly and positively identified. Barcode scanners, wireless data terminals and portable barcode label printers enable healthcare professionals to positively identify specimens at the bedside as

they are collected. Key benefits:

o o o

Positively identifies specimen at point of collection. Reduces costs associated with re-testing and re-treatment. Provides caregiver with an efficient means for accurate labeling of containers.

Blood Transfusion Verification Accurate matching of blood to patients is critically important to avoiding life-threatening errors. Barcode scanners, mobile computers and barcode label printers assure accuracy in identification of blood, from the moment it is drawn to when it is given to the laboratory. Key benefits:

o o o

Scanning blood bags at bedside eliminates redundant cross-checks and greatly reduces the possibility of a mis-matched transfusion. Data such as blood information, donor, expiration date and serial number can be immediately accessed. Manage available blood inventory by knowing what is in stock, what is being used, and what is needed.

AMERICAN SOCIETY OF HEALTH-SYSTEM PHARMACISTS (ASHP) is a professional organization representing the interests of pharmacists who practice in hospitals, health maintenance organizations, long-term care facilities, home care, and other components of health care systems. The mission of the society is to advance and support the professional practice of pharmacists in hospitals and health systems and serve as their collective voice on issues related to medication use and public health. ASHP provides legislative advocacy on health system pharmacy issues, partly to achieve public policy that helps people make the best use of medicines. ASHP attempts to assure that there are enough competent pharmacists in hospitals and other health care facilities to improve the safety and accessibility of medication to patients. ASHP provides professional advocacy on health system pharmacy issues to government agencies, such as Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC) and healthcare organizations like Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Institute of Medicine (IOM). AUTOMATED DISPENSING CABINET (ADC) An automated dispensing cabinet (ADC) is a computerized drug storage device or cabinet designed for hospitals. ADCs allow medications to be stored and dispensed near the point of care while controlling and tracking drug distribution. They also are called unit-based cabinets (UBCs), automated dispensing devices (ADDs), automated distribution cabinets or automated dispensing machines (ADMs). ADCs are more than automated teller machines for drugs and reflect how design advances as well as, specific technologies, such as barcode scanning and clinical decision support, can improve medication safety. Over the years, ADCs have been adapted to facilitate compliance with emerging regulatory requirements such as pharmacy review of medication orders and safe practice recommendations. Automated dispensing cabinets incorporate sophisticated software and electronic interfaces to synthesize high-risk steps in the medication use process. These unit-based medication repositories provide computer controlled storage, dispensation, tracking, and documentation of medication distribution on the resident care unit. Since automated dispensing cabinets are not located in the pharmacy, they are considered “decentralized” medication distribution systems. Instead, they can be found at the point of care on the resident care unit. Tracking of the stocking and distribution process can occur by interfacing the unit with a central pharmacy computer. These cabinets can also be interfaced with other external databases such as resident profiles, the facility’s admission/discharge/transfer system, and billing systems. ADCs are designed to meet the exact needs of the nurses and pharmacists that use them. When ADCs are purchased for a facility, the order is customized for whatever the cabinet will be specifically used for.

SMART INFUSION PUMP DELIVERY SYSTEMS An infusion pump infuses fluids, medication or nutrients into a patient's circulatory system. It is generally used intravenously, although subcutaneous, arterial and epidural infusions are occasionally used. Fallback: Infusion pumps can administer fluids in ways that would be impractically expensive or unreliable if performed manually by nursing staff. For example, they can administer as little as 0.1 mL per hour injections (too small for a drip), injections every minute, injections with repeated boluses requested by the patient, up to maximum number per hour (e.g. in patient-controlled analgesia), or fluids whose volumes vary by the time of day. Smart pumps are designed to offer extra bedside protection against mistakes. The pumps' software can hold an extensive drug library that includes pre-established maximum and minimum range doses for each medication. A warning sounds if a staffer tries to exceed these doses. The pump may give a "soft alert," which asks users to reconsider whether they want to program that particular dose. A "hard alert" will not allow users to override the machine and administer a dose outside of the library's limits. FAILURE MODE AND EFFECT ANALYSIS A failure modes and effects analysis (FMEA) is a procedure in product development and operations management for analysis of potential failure modes within a system for classification by the severity and likelihood of the failures. A successful FMEA activity helps a team to identify potential failure modes based on past experience with similar products or processes, enabling the team to design those failures out of the system with the minimum of effort and resource expenditure, thereby reducing development time and costs. It is widely used in manufacturing industries in various phases of the product life cycle and is now increasingly finding use in the service industry. Failure modes are any errors or defects in a process, design, or item, especially those that affect the customer, and can be potential or actual. Effects analysis refers to studying the consequences of those failures.

HIGH ALERT MEDICATION High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Strategies like improving access to information about these drugs; limiting access to high-alert medications; using auxiliary labels and automated alerts; standardizing the ordering, storage, preparation, and administration of these products; and employing redundancies such as automated or independent doublechecks when necessary could decrease the risk. gories of Medications ISMP’s LIST OF HIGH ALERT MEDICATIONS Classes/Categories of Medications • adrenergic agonists, IV (e.g., epinephrine, phenylephrine, norepinephrine) • adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol) • anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine) • antiarrhythmics, IV (e.g., lidocaine, amiodarone) • antithrombotic agents (anticoagulants), including warfarin, low-molecular-weight heparin, IV unfractionated heparin, Factor Xa inhibitors (fondaparinux), direct thrombin inhibitors (e.g., argatroban, lepirudin, bivalirudin), thrombolytics (e.g., alteplase, reteplase, tenecteplase), and glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide) • cardioplegic solutions • chemotherapeutic agents, parenteral and oral • dextrose, hypertonic, 20% or greater • dialysis solutions, peritoneal and hemodialysis • epidural or intrathecal medications • hypoglycemics, oral • inotropic medications, IV (e.g., digoxin, milrinone) • liposomal forms of drugs (e.g., liposomal amphotericin B) • moderate sedation agents, IV (e.g., midazolam) • moderate sedation agents, oral, for children (e.g., chloral hydrate) • narcotics/opiates, IV, transdermal, and oral (including liquid concentrates, immediate and sustained-release formulations) • neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium) • radiocontrast agents, IV • total parenteral nutrition solutions

Specific Medications • colchicine injection*** • epoprostenol (Flolan), IV • insulin, subcutaneous and IV • magnesium sulfate injection • methotrexate, oral, non-oncologic use • opium tincture • oxytocin, IV • nitroprusside sodium for injection • potassium chloride for injection concentrate • potassium phosphates injection • promethazine, IV • sodium chloride for injection, hypertonic (greater than 0.9% concentration) • sterile water for injection, inhalation, and irrigation (excluding pour bottles) in containers of 100 mL or more eMAR/ Medication Order Entry/ Administration (MOE/MAR) The MOE/MAR project implemented both electronic medication order entry and an electronic medication administration record as part of the Electronic Patient Record. The redesign of workflow and the elimination of transcription have improved patient safety. Electronic Medication Administration Record (eMAR), a fully-integrated software, eMAR with two technologies: Bluetooth(r) wireless and hand-held scanners to read bar codes: the same bar code technology used in supermarkets. Individual dosages of drugs are bar coded in the Doylestown Hospital Pharmacy, then tracked from the Pharmacy to the Nursing Unit to the patient's bedside. At admission, all patients are given bar coded ID bracelets to be used for identification. The nurse scans a patient's bracelet at the bedside before medications are administered. If the nurse scans the wristband and medication, and the software detects a medication interaction, incompatibility or allergy, the eMAR system alerts the nurse. It also prompts the caregiver to check clinical information related to certain medications. EMAR ensures easy tracking of medications from the physician's order, to the Pharmacy, to the floor's medication carts, to the patient. Other local hospitals use components of Meditech's eMAR system, but none use the bar coding like Doylestown does. The Medication Administration Process Using eMAR

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A Physician writes the order, which is sent to the Pharmacy. A Pharmacist enters the order in Meditech (a specialized healthcare software provider) The Pharmacy bar codes the medication and distributes to the floors. The nurse views the eMAR screen and reviews the patient's medication list and verifies with the physician orders. eMAR alerts the nurse about the next dose due, overdue doses, or cautions about medications Nurse takes the cart to the patient, scans the medication and the patient's wristband.

HEALTH CARE DATA STANDARDS Health care data interchange standards Clinical Data Interchange Standards Consortium (CDISC) is a non-profit organization, whose mission is "to develop and support global, platform-independent data standards that enable information system interoperability to improve medical research and related areas of health-care". Their main project, the described data standard, bears the same name. The data standards are defined

as a series of Models, which can be expressed using an underlying electronic format. The preferred electronic format is XML, using the Operational Data Model (ODM) as a base XML Schema.

Recommendations of The national committee on vital and health statistics The National Committee on Vital and Health Statistics was established by Congress to serve as an advisory body to the Department of Health and Human Services on health data, statistics and national health information policy. It fulfills important review and advisory functions relative to health data and statistical problems of national and international interest, stimulates or conducts studies of such problems and makes proposals for improvement of the Nation’s health statistics and information systems. In 1996, the Committee was restructured to meet expanded responsibilities under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Committee has been associated with ground-breaking contributions in such areas as disease classification, health surveys, uniform health data sets and other data standards, data needs for minority and other special populations, mental health statistics, State and community health data needs, and privacy protection for health information. The NCVHS is in a unique position to serve as a national forum for the collaboration of interested parties, with the long-term goal of improving the compatibility of private sector, state, and federal health information systems while assuring the confidentiality of the information collected. In particular, the new charter enables the NCVHS to foster collaboration on voluntary means to facilitate and accelerate the development of consensus across the public and private sectors around these key data standards and privacy issues. The National Committee on Vital and Health Statistics (NCVHS) was called upon to "study the issues related to the adoption of uniform data standards for patient medical record information [PMRI] and the electronic exchange of such information." Standards for PMRI are important because they will facilitate significant improvements in the quality of patient care, promote patient safety, control rising healthcare costs, enhance the productivity of clinical research and strengthen the nation's ability to identify and respond to healthcare emergencies. They are critical to the creation of a National Health Information Infrastructure. Guiding Principles Used as Criteria for Selection- NCVHS recommendations for PMRI message format standards are selected from the responses to the PMRI questionnaire of six SDOs:

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ASTM (American Society for Testing and Materials) DICOM (Digital Image Communications) HL7 (Health Level Seven) IEEE (Institute of Electrical and Electronic Engineers) NCPDP (National Council for Prescription Drug Programs) Object Management Group, Healthcare Domain Task Force

The Committee emphasized the following four criteria derived from the PMRI guiding principles: • The degree of market acceptance of the standard • The extent to which the standard enables interoperability between information systems • The ability of the standard to facilitate the comparability of data • The aspects of the standard that support data quality, accountability and integrity

Recognition of Current Standards and Incentives for Emerging Standards

NCVHS has recognized the important role played by PMRI standards currently used by the healthcare industry. Because it has taken years for several of today's standards to achieve broad market acceptance, they are based on older conceptual models. Those models do not uniformly provide the high degree of interoperability and data comparability that are necessary to support significant improvements in healthcare cost, quality and productivity. To promote more rapid realization of these benefits in accordance with the prior recommendations in the PMRI report, NCVHS is recommending that HHS provide specific incentives to accelerate the development and early adoption of emerging PMRI standards as well as recognize current standards.

Recommendations Encourage HHS Guidance and Incentives Rather Than Mandates

NCVHS recommends that HHS set forth guidance for industry use of PMRI message format standards and migration to new versions, rather than create new federal regulations. NCVHS also recommends that the Secretary direct government agencies to follow this guidance by becoming early adopters of emerging PMRI standards, thereby serving as an example and as an incentive to the industry. NCVHS further recommends that HHS use its healthcare market position to promote and encourage the use of PMRI standards.

NCVHS Recommendations for Specific PMRI Message Format Standards

NCVHS recommends that HL7 be recognized as the core PMRI standard and that DICOM, NCPDP SCRIPT and IEEE 1073 be recognized as standards for specific PMRI market segments. The recommendations for all of these PMRI standards are set forth in a framework identifying which version of the standard should be considered as retired, current, or emerging.

NCVHS recommends that HHS recognize the following PMRI message format standard as retiredHealth Level Seven (HL7 v2.1)

HHS Guidance to Government and Industry--Users should specify that no new products using this version of the HL7 standard be purchased or developed. Vendors and users should plan to upgrade any system using HL7 v2.1 to a current version of HL7.

the current PMRI message format standard -Health Level Seven (HL7 v2.2, v2.3, v2.4, and later v2.x) This includes standards for the following transaction sets: • Order Entry • Scheduling • Medical Record/Image Management • Patient Administration • Observation Reporting • Financial Management • Patient Care HHS Guidance to Government and Industry--HHS recognition of HL7 versions 2.2, 2.3, 2.4 and later v2.x, as current standards means that vendors and users of these versions will not be asked to migrate to newer versions until the more advanced version is fully implementable with the supporting implementation guides and conformance tests.

• NCVHS recommends that HHS recognize the following HL7 versions and transaction sets as

NCVHS recommends that HHS recognize the following PMRI message format standard as an emerging standard based on its potential to provide superior levels of interoperability and data comparability - Health Level Seven (HL7 version 3)

This includes standards for the following transaction sets: • v3 Administrative Management • v3 Health and Clinical Management • v3 Infrastructure Management

NCVHS recommends that HHS provide incentives to accelerate the development and early adoption of HL7 version 3 standards. These incentives should include but not necessarily be limited to the funding of publication of version 3 implementation guides and the development of conformance tests, and the early adoption of version 3 standards by government agencies. NCVHS recommends that HHS recognize the following as current PMRI market segment message format standards based on their market acceptance, ability to address specific market segment needs, and their cost effectiveness.

Digital Imaging and Communications in Medicine (DICOM)--This standard supports retrieval of information from imaging devices/equipment to diagnostic and review workstations, and to short-term and long-term storage systems. NCPDP SCRIPT Standard--This standard communicates prescription information between prescribers and pharmacies. These transactions include new prescriptions, prescription refill requests, prescription fill status notifications, and cancellation notifications. HHS Guidance to Government and Industry--New users should adopt the latest versions of the DICOM and NCPDP SCRIPT PMRI market segment standards whenever possible.

NCVHS recommends that HHS recognize the following as an emerging PMRI market segment message format standard based on its potential for vendor acceptance and its anticipated ability to address specific market segment needs.

IEEE 1073 (1.1.1, 1.2.1, 1.3, 2.1.1, 3.2)--This is a set of medical device communications standards also known as ISO 11073 standards. These standards communicate patient data from medical devices typically found in acute- and chronic-care environments (e.g., patient monitors, ventilators, infusion pumps, etc.).

NCVHS recommends that HHS encourage PMRI SDOs to share their data elements and data definitions with the U.S. Health Information Knowledgebase (a metadata registry). Additionally,

HHS should encourage PMRI SDOs to continue their collaboration to reduce or eliminate duplicate or inconsistent data elements especially those for patient information. Furthermore, HHS should encourage PMRI SDOs to harmonize their data elements and data definitions for future versions so that they are consistent with the HL7 Reference Information Model (RIM).

NCVHS also recommends that HHS provide funding to support PMRI SDO collaborative efforts toward harmonization.

Health level 7 (HL7) STANDARDS Health Level Seven (HL7) is an all-volunteer, non-profit organization involved in development of international healthcare informatics interoperability standards. "HL7" is also used to refer to some of the specific standards created by the organization (e.g., HL7 v2.x, v3.0, HL7 RIM). HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information. v2.x of the standards, which support clinical practice and the management, delivery, and evaluation of health services, are the most commonly used in the world. Hospitals and other healthcare provider organizations typically have many different computer systems used for everything from billing records to patient tracking. All of these systems should communicate with each other (or "interface") when they receive new information but not all do so. HL7 specifies a number of flexible standards, guidelines, and methodologies by which various healthcare systems can communicate with each other. Such guidelines or data standards are a set of rules that allow information to be shared and processed in a uniform and consistent manner. These data standards are meant to allow healthcare organizations to easily share clinical information. Theoretically, this ability to exchange information should help to minimize the tendency for medical care to be geographically isolated and highly variable. HL7 develops conceptual standards (e.g., HL7 RIM), document standards (e.g., HL7 CDA), application standards (e.g., HL7 CCOW), and messaging standards (e.g., HL7 v2.x and v3.0). Messaging standards are particularly important because they define how information is packaged and communicated from one party to another. Such standards set the language, structure and data types required for seamless integration from one system to another. HL7 encompasses the complete life cycle of a standards specification including the development, adoption, market recognition, utilization, and adherence. Business use of the HL7 standards requires a paid organizational membership in HL7 Inc. HL7 Members can access standards for free and non members can buy the standards from HL7 or ANSI. HL7 version 2.x The HL7 version 2 standard has the aim to support hospital workflows. It was originally created in 1989.[7] V2.x Messaging HL7 version 2 defines a series of electronic messages to support administrative, logistical, financial as well as clinical processes. Since 1987 the standard has been updated regularly, resulting in versions 2.1, 2.2, 2.3, 2.3.1, 2.4, 2.5, 2.5.1 and 2.6. The v2.x standards are backward compatible (i.e. a message based on version 2.3 will be understood by an application that supports version 2.6). HL7 v2.x mostly uses a textual, non-XML encoding syntax based on delimiters. HL7 v2.x has allowed for the interoperability between electronic Patient Administration Systems (PAS), Electronic Practice Management (EPM) systems, Laboratory Information Systems (LIS), Dietary, Pharmacy and Billing systems as well as Electronic Medical Record (EMR) or Electronic Health Record (EHR) systems. Currently, HL7’s v2.x messaging standard is supported by every major medical information systems vendor in the United States. HL7 version 3 The HL7 version 3 standard has the aim to support all healthcare workflows. Development of version 3 started around 1995, resulting in an initial standard publication in 2005. The v3 standard, as opposed to version 2, is based on a formal methodology (the HDF) and object-oriented principles. RIM - ISO/HL7 21731 The Reference Information Model (RIM) is the cornerstone of the HL7 Version 3 development process and an essential part of the HL7 V3 development methodology. RIM expresses the data content needed in a specific clinical or administrative context and provides an explicit representation of the

semantic and lexical connections that exist between the information carried in the fields of HL7 messages. The RIM is essential to increase precision and reduce implementation costs. Models are available. HL7 Development Framework - ISO/HL7 27931 The HL7 Version 3 Development Framework (HDF) is a continuously evolving process that seeks to develop specifications that facilitate interoperability between healthcare systems. The HL7 RIM, vocabulary specifications, and model-driven process of analysis and design combine to make HL7 Version 3 one methodology for development of consensus-based standards for healthcare information system interoperability. The HDF is the most current edition of the HL7 V3 development methodology. The HDF not only documents messaging, but also the processes, tools, actors, rules, and artifacts relevant to development of all HL7 standard specifications. Eventually, the HDF will encompass all of the HL7 standard specifications, including any new standards resulting from analysis of electronic health record architectures and requirements. HL7 specifications draw upon codes and vocabularies from a variety of sources. The V3 vocabulary work ensures that the systems implementing HL7 specifications have an unambiguous understanding of the code sources and code value domains they are using. V3 Messaging The HL7 version 3 messaging standard defines a series of electronic messages (called interactions) to support all healthcare workflows. HL7 v3 messages are based on an XML encoding syntax. V3 Clinical Document Architecture - ISO 10781 The HL7 version 3 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. Digital Imaging Communication in Medicine Standards Committee (DIGICOM) STANDARD Digital Imaging and Communications in Medicine (DICOM) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. The communication protocol is an application protocol that uses TCP/IP to communicate between systems. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. The National Electrical Manufacturers Association (NEMA) holds the copyright to this standard. It was developed by the DICOM Standards Committee, whose members are also partly members of NEMA. DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving and communication system (PACS). The different devices come with DICOM conformance statements which clearly state the DICOM classes they support. DICOM has been widely adopted by hospitals and is making inroads in smaller applications like dentists' and doctors' offices. DICOM is known as NEMA standard PS3, and as ISO standard 12052:2006 "Health informatics -- Digital imaging and communication in medicine (DICOM) including workflow and data management" National Council for Prescription Drug Programs (NCPDP) National Council for Prescription Drug Programs (NCPDP) was founded in 1977 as the extension of a Drug Ad Hoc Committee that made recommendations for the US National Drug Code (NDC). NCPDP is a not-for-profit, ANSI-accredited, standards development organization with over 1575 members representing virtually every sector of the pharmacy services industry. The diverse membership provides leadership and healthcare business solutions through education and standards, created using the consensus building process. NCPDP has been named in US federal legislation, including Health Insurance Portability and Accountability Act and the Medicare Prescription Drug, Improvement, and Modernization Act. NCPDP members have created standards such as the Telecommunication Standard and Batch Standard, the SCRIPT Standard for Electronic Prescribing, the Manufacturers Rebate Standard and more to improve communication within the pharmacy industry. NCPDP has twelve active work groups where electronic standards for transmission of pharmacy data are created and modified. Accredited Standards Committee x12N/Insurance- The Accredited Standards Committee (ASC) X12, chartered by the American National Standards Institute in 1979, develops electronic data interchange (EDI) standards and related documents for national and global markets. With more than 315 X12 EDI standards and a growing collection of X12 XML schemas, ASC X12 enhances business

processes, reduces costs and expands organizational reach. ASC X12's diverse member base includes 3,000+ standards experts representing over 340 companies from multiple business domains, including communications, finance, government, insurance, supply chain and transportation. TERMINOLOGIES: ICD 9 CM The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. These codes are in the public domain (ex. ICD9-cm).

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List of ICD-9 codes 001–139: infectious and parasitic diseases List of ICD-9 codes 140–239: neoplasms List of ICD-9 codes 240–279: endocrine, nutritional and metabolic diseases, and immunity disorders List of ICD-9 codes 280–289: diseases of the blood and blood-forming organs List of ICD-9 codes 290–319: mental disorders List of ICD-9 codes 320–359: diseases of the nervous system List of ICD-9 codes 360–389: diseases of the sense organs List of ICD-9 codes 390–459: diseases of the circulatory system List of ICD-9 codes 460–519: diseases of the respiratory system List of ICD-9 codes 520–579: diseases of the digestive system List of ICD-9 codes 580–629: diseases of the genitourinary system List of ICD-9 codes 630–679: complications of pregnancy, childbirth, and the puerperium List of ICD-9 codes 680–709: diseases of the skin and subcutaneous tissue List of ICD-9 codes 710–739: diseases of the musculoskeletal system and connective tissue List of ICD-9 codes 740–759: congenital anomalies List of ICD-9 codes 760–779: certain conditions originating in the perinatal period List of ICD-9 codes 780–799: symptoms, signs, and ill-defined conditions List of ICD-9 codes 800–999: injury and poisoning List of ICD-9 codes E and V codes: external causes of injury and supplemental classification

ICD 10 CM International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), for medical coding and reporting in the United States. The ICD-10-CM is a morbidity classification for classifying diagnoses and reason for visits in all American health care settings. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO) which replaces ICD-9. 1 Conventions

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1.1 Level of Detail in Coding 1.2 Seventh character and placeholders 1.3 Excludes Notes

2 CHAPTER 1 - Certain infectious and parasitic diseases (A00-B99) 3 CHAPTER 2 - Neoplasms (C00-D48) 4 CHAPTER 3 - Diseases of the blood and blood-forming organs and certain disorders involving the Immune mechanism (D50-D89) 5 CHAPTER 4 - Endocrine, nutritional and metabolic diseases (E00-E90) 6 CHAPTER 5 - Mental and behavioral disorders (F01-F99) 7 CHAPTER 6 - Diseases of the nervous system (G00-G99) 8 CHAPTER 7 - Diseases of the eye and adnexa (H00-H59) 9 CHAPTER 8 - Diseases of the ear and mastoid process (H60-H95) 10 CHAPTER 9 - Diseases of the circulatory system (I00-I99) 11 CHAPTER 10 - Diseases of the respiratory system (J00-J99) 12 CHAPTER 11 - Diseases of the digestive system (K00-K93) 13 CHAPTER 12 - Diseases of the skin and subcutaneous tissue (L00-L99) 14 CHAPTER 13 - Diseases of the musculoskeletal system and connective tissue (M00-M99)= 15 CHAPTER 14 - Diseases of the genitourinary system (N00-N99) 16 CHAPTER 15 - Pregnancy, childbirth and the puerperium (O00-O99) 17 CHAPTER 16 - Certain conditions originating in the perinatal period (P00-P96) 18 CHAPTER 17 - Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 19 CHAPTER 18 - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 20 CHAPTER 19 - Injury, poisoning and certain other consequences of external causes (S00-T98)

21 CHAPTER 20 - External causes of morbidity (V01-Y99) 22 CHAPTER 21 - Factors influencing health status and contact with health services (Z00-Z99) 23 7th Character

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23.1 M1a 23.2 M48.4 - M48.5 23.3 M80, M84.3 - M84.6 23.4 O31 - O32, O33.4 - O33.7, O35 - O41, O60.1 - O60.2, O64, O69, 23.5 R40.21, R40.22, R40.23 23.6 S00 - S78 23.7 S79.0, S79.1 23.8 S79.8, S79.9, S80 - S81, S83 - S88, S89.8, S89.9, S90 - S99 23.9 S82 23.10 S89.0, S89.1, S89.2, S89.3 23.11 T15 - T28, T33 - T85, T88 23.12 V00 - V99, W00 - W99, X00 - X99, Y00 - Y04, Y08 - Y38,

CPT-4 CODE SET The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set accurately describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. The current version is the CPT 2010. There are three types of CPT codes:

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Category I CPT Code(s) Category II CPT Code(s) – Performance Measurement Category III CPT Code(s) – Emerging Technology

CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Health Care Procedure Coding System.

SNOMED SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms), is a systematically organized computer processable collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organizing the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research. SNOMED CT consists of over a million medical Concepts. For example 22298006 means myocardial infarction (MI). The Concepts are arranged in a type or IS-A hierarchy. For example, Viral pneumonia IS-A Infectious pneumonia IS-A Pneumonia IS-A Lung disease. Concepts may have multiple parents, for example Infectious pneumonia is also an Infectious disease. The Concept graph must be acyclic — a parent cannot be its own child. Concepts can have Roles, e.g. Viral pneumonia has a role Causitive Agent which must be a Virus. Some Concepts can be Primitive, such as Virus. But SNOMED also allows concepts to be Defined by a predicate. For example Viral pneumonia might be defined as Pneumonia that is caused by a Virus. Defined concepts are based on Description Logic. Descriptions are Terms or names (synonyms) assigned to a concept. Concepts often have several Descriptions, and a description may sometimes refer to more than one concept. For example, Immunosuppression might be a Therapy or a Finding. Upper level concepts include Procedure, Pharmaceutical/biologic product, Clinical finding, Event, Body structure, Organism. SNOMED concepts are often referred to by an information model such as HL7. Sample Computer Applications Using SNOMED CT

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Electronic Health Record Systems Computerized Provider Order Entry CPOE Such As E-Prescribing Or Laboratory Order Entry Catalogues of clinical services e.g. for Diagnostic Imaging procedures Knowledge databases used in clinical decision support CDSS Remote Intensive Care Unit Monitoring Laboratory Reporting

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Emergency Room Charting Cancer Reporting Genetic Databases

LOINC STANDARDS Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. It was developed and is maintained by the Regenstrief Institute, Inc., a US non-profit medical research organization, in 1994. LOINC was created in response to the demand for an electronic database for clinical care and management and is publicly available at no cost. It is endorsed by the American Clinical Laboratory Association and the College of American Pathologist. Since its inception, the database has expanded to include not just medical and laboratory code names, but also: nursing diagnosis, nursing interventions, outcomes classification, and patient care data set. LOINC applies universal code names and identifiers to medical terminology related to the Electronic health record. The purpose is to assist in the electronic exchange and gathering of clinical results (such as laboratory tests, clinical observations, outcomes management and research). Several standards, such as IHE, HL7 or openEHR, to electronically transfer results from different reporting systems to the appropriate healthcare networks. However, the health information enclosed is identified by a multiplicity of code values that may vary according to the entity producing those results. This has obvious disadvantages to the healthcare network that may need to adopt different codes to access and manage information coming from multiple sources. Managed care providers, for example, often have negotiated contracts that reimburse episodes of care and unique coding to trigger automated claim payment. Mapping each entity-specific code to its corresponding universal code can represent a significant investment of both human and financial capital. A universal code system will enable facilities and departments across the world to receive and send results from their areas for comparison and consultation and contribute toward a larger public health initiative of improving clinical outcomes and quality of care. LOINC is one of the standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information. In 1999, it was identified by the HL7 Standards Development Organization as a preferred code set for laboratory test names in transactions between health care facilities, laboratories, laboratory testing devices, and public health authorities. A formal, distinct, and unique 6-part name is given to each term for test or observation identity. The database currently has over 58,000 observation terms that can be accessed and understood universally. Each database record includes six fields for the unique specification of each identified single test, observation, or measurement: 1. 2. 3. 4. 5. 6. Component- what is measured, evaluated, or observed (example: urea,...) Kind of property- characteristics of what is measured, such as length, mass, volume, time stamp and so on Time aspect- interval of time over which the observation or measurement was made System- context or specimen type within which the observation was made (example: blood, urine,...) Type of scale- the scale of measure. The scale may be quantitative, ordinal, nominal or narrative Type of method- procedure used to make the measurement or observation

A unique code (format: nnnnn-n) is assigned to each entry upon registration. Other database fields include status and mapping information for database change management, synonyms, related terms, substance information (e.g. molar mass, CAS registry number), choices of answers for nominal scales, translations. Some of the advantages resulting from adopting LOINC may include improved communication in integrated healthcare delivery networks, improved community wide electronic health records, the automatic transfer to public health authorities of case reports for reportable diseases (e.g. for disease control or detection of epidemics), improved transfer of payment information for services rendered and a significant improvement in the overall quality of health care by reducing errors in the system. The fact that universal standards are being promoted (if not adopted by national organizations and agencies) is an indication that the dialogue will continue regarding the development, structure, financing, monitoring, enforcement, and integration of standards within the broader health care system.

International interest in LOINC continues to grow. A number of efforts have been undertaken to translate the LOINC documents and terms into various languages, such as Simplified Chinese, German, Spanish. For more information on LOINC International, see LOINC International. Currently(as of January, 2009), the software RELMA (Regenstrief LOINC Mapping Assistant) is available in separate downloads that contain an additional word index in Spanish, Simplified Chinese, or Korean, which allows searching in these languages in addition to English RxNORM STANDARDS RxNorm provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software, including those of First Databank, Micromedex, MediSpan, Gold Standard Alchemy, and Multum. By providing links between these vocabularies, RxNorm can mediate messages between systems not using the same software and vocabulary. RxNorm now includes the National Drug File - Reference Terminology (NDF-RT) from the Veterans Health Administration. NDF-RT is a terminology used to code clinical drug properties, including mechanism of action, physiologic effect, and therapeutic category. UNIFIED MEDICAL LANGUAGE SYSTEM The Unified Medical Language System (UMLS) is a compendium of many controlled vocabularies in the biomedical sciences (created 1986[1]). It provides a mapping structure among these vocabularies and thus allows one to translate among the various terminology systems; it may also be viewed as a comprehensive thesaurus and ontology of biomedical concepts. UMLS further provides facilities for natural language processing. It is intended to be used mainly by developers of systems in medical informatics. UMLS consists of Knowledge Sources (databases) and a set of software tools. The UMLS was designed and is maintained by the US National Library of Medicine, is updated quarterly and may be used for free. The project was initiated in 1986 by Donald A. B. Lindberg, M.D., then and current Director of the Library of Medicine. The number of biomedical resources available to researchers is enormous. Often this is a problem due to the large volume of documents retrieved when the medical literature is searched. The purpose of the UMLS is to enhance access to this literature by facilitating the development of computer systems that understand biomedical language. This is achieved by overcoming two significant barriers: "the variety of ways the same concepts are expressed in different machine-readable sources & by different people" and "the distribution of useful information among many disparate databases & systems". The UMLS can be used to design information retrieval or patient record systems, to facilitate the communication between different systems, or to develop systems that parse the biomedical literature. For many of these applications, the UMLS will have to be customized locally according to one's particular needs. The Library of Medicine itself uses it for its PubMed and ClinicalTrials.gov systems. Integrating health care enterprise (IHE) IHE is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. In 1997, a consortium of radiologists and information technology experts formed IHE, or "Integrating the Healthcare Enterprise." IHE created and operates a process through which interoperability of health care IT systems can be improved. The group gathers case requirements, identifies available standards, and develops technical guidelines that manufacturers can implement. IHE also stages "connectathons" and "interoperability showcases" in which vendors assemble to demonstrate the interoperability of their products. IHE is an international organization that focuses on the development of open and global IHE Integration Profiles and on the regional deployment of interoperable IT systems. Because of its limited resources, IHE concentrates on specific projects. It solicits proposals; and after surveying its members to better understand their priorities, it chooses areas to focus on. IHE Integration Profiles describe a clinical information need or workflow scenario and document how to use established standards (e.g. HL7, DICOM, LOINC...) to accomplish it. A group of systems that implement the same Integration Profile address the need/scenario in a mutually compatible way. Integration Profiles describe basic functional elements and therefore are reusable in many IT applications. More characteristics are:

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each Integration Profile is based on relevant use-cases described by real users Integration Profiles are independent of manufacturers or products Integration Profiles are stable once published and may be extended by amendments - rather than re-written.

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Integration Profiles provide an implementation guide for equipment vendors Integration Profiles are an effective shorthand for healthcare providers to specify integration requirements when purchasing systems and therefore achieved considerable recognition in the market. IHE Integration Statements are simple documents prepared and published by a vendor to list the IHE Profiles supported by a specific release of a specific product. IHE Technical Frameworks are the detailed documents which specify the Integration Profiles and the associated actors (systems) and transactions. IHE Connectathons are annual events where equipment vendors bring products with IHE Profiles and test them with other vendors. American society for testing and materials(ASTM) ASTM International (ASTM), originally known as the American Society for Testing and Materials, is an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services. The organization's headquarters is in West Conshohocken, Pennsylvania, about 5 miles (8 km) northwest of Philadelphia. ASTM has a dominant role among standards developers in the USA, and claims to be the world's largest developer of standards. Using a consensus process, ASTM supports thousands of volunteer technical committees, which draw their members from around the world and collectively develop and maintain more than 12,000 standards. International Organization of Standardization (ISO) The International Organization for Standardization widely known as ISO, is an international standard-setting body composed of representatives from various national standards organizations. Founded on February 23, 1947, the organization promulgates worldwide proprietary industrial and commercial standards. It has its headquarters in Geneva, Switzerland. While ISO defines itself as a non-governmental organization, its ability to set standards that often become law, either through treaties or national standards, makes it more powerful than most non-governmental organizations. American National Standards Institute The American National Standards Institute or ANSI is a private non-profit organization that oversees the development of voluntary consensus standards for products, services, processes, systems, and personnel in the United States. The organization also coordinates U.S. standards with international standards so that American products can be used worldwide. For example, standards ensure that people who own cameras can find the film they need for that camera anywhere around the globe. ANSI accredits standards that are developed by representatives of standards developing organizations, government agencies, consumer groups, companies, and others. These standards ensure that the characteristics and performance of products are consistent, that people use the same definitions and terms, and that products are tested the same way. ANSI also accredits organizations that carry out product or personnel certification in accordance with requirements defined in international standards. The organization's headquarters are in Washington, DC. ANSI's operations office is located in New York City. The ANSI annual operating budget is funded by the sale of publications,

membership dues and fees, accreditation services, fee-based programs, and international standards programs.

HIPAA The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-191) [HIPAA] was enacted by the U.S. Congress in 1996. It was originally sponsored by Sen. Edward Kennedy and Sen. Nancy Kassebaum. According to the Centers for Medicare and Medicaid Services (CMS) website, Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. The Administration Simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by

encouraging the widespread use of electronic data interchange in the U.S. health care system. Consolidated Health Informatics (CHI) CHI is a collaborative effort to adopt health information interoperability standards, particularly health vocabulary and messaging standards, for implementation in federal government systems. About 20 department/agencies including the Department of Health and Human Services, the Department of Defense and the Department of Veteran's Affairs are active in the CHI governance process. Originally, CHI identified a portfolio of 24 health domains that later expanded to 27. CHI adopted 20 uniform standards for electronic exchange of clinical information to be used across the federal health enterprise. Phase I ended in May 2004. In Phase II, CHI is focusing on

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Implementation of adopted standards, Maintenance of adopted standards, and Identification and adoption of new standards.

CHI is an integral element of the Federal Health Architecture (FHA) Program that is in the Office of the National Coordinator for Health Information Technology. STANDARDS DEVELOPMENT PROCESS ISO standards are developed according to the following principles.

Consensus The views of all interests are taken into account: manufacturers, vendors and users, consumer groups, testing laboratories, governments, engineering professions and research organizations. Industry wide Global solutions to satisfy industries and customers worldwide.

Voluntary International standardization is market driven and therefore based on voluntary involvement of all interests in the market-place.

There are three main phases in the ISO standards development process as follows. 1. The need for a standard is usually expressed by an industry sector, which communicates this need to a national member body. The latter proposes the new work item to ISO as a whole. Once the need for an International Standard has been recognized and formally agreed, the first phase involves definition of the technical scope of the future standard. This phase is usually carried out in working groups which comprise technical experts from countries interested in the subject matter. Once agreement has been reached on which technical aspects are to be covered in the standard, a second phase is entered during which countries negotiate the detailed specifications within the standard. This is the consensus-building phase. The final phase comprises the formal approval of the resulting draft International Standard (the acceptance criteria stipulate approval by two-thirds of the ISO members that have participated actively in the standards development process, and approval by 75% of all members that vote), following which the agreed text is published as an ISO International Standard.

2. 3.

It is also possible to publish interim documents at different stages in the standardization process. Most standards require periodic revision. Several factors combine to render a standard out of date: technological evolution, new methods and materials, new quality and safety requirements. To take account of these factors, ISO has established the general rule that all ISO standards should be reviewed at intervals of not more than five years. On occasion, it is necessary to revise a standard earlier. ELECTRONIC HEALTH RECORD An electronic health record (EHR) (also electronic patient record (EPR) or computerised patient record) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected

enterprise-wide information systems. Such records may include a whole range of data in comprehensive or summary form, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information. Its purpose can be understood as a complete record of patient encounters that allows the automation and streamlining of the workflow in health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting. Benefits: Reduction of cost In the U.S. a vast amount of funds are allocated towards the health care industry—more than $1.7 trillion per year. If savings are allocated using the current level of spending from the National Health Accounts, Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year. Improve quality of care The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality. Information Technology is being used today to automate day-to-day processes, thus helping to reduce administration costs which then in turn can free up time and money for patient care. EHR systems can help reduce medical errors by providing healthcare workers with decision support. Fast access to medical literature and current best practices in medicine are hypothesised to enable proliferation of ongoing improvements in healthcare efficacy. Improved usage of EHR is achieved if the presentation on screen or on paper is not just longitudinal, but hierarchically ordered and layered. During compilation while hospitalisation or ambulant serving of the patient, easing to get access on details is improved with browser capabilities applied to screen presentations also cross referring to the respective coding concepts ICD, DRG and medical procedures information. Computerized Physician Order Entry (CPOE)—one component of EHR—increases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals. Promote evidence-based medicine EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices. Realistically, these benefits may only be realized if the EHR systems are interoperable and wide spread (for example, national or regional level) so that various systems can easily share information. Also, to avoid failures that can cause injury to the patient and violations to privacy, the best practices in software engineering and medical informatics must be deployed. Record keeping and mobility EHR systems have the advantages of being able to connect to many electronic medical record systems. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure.It is also easier to check in their records whether a patient as been admitted to such a medical centre or if they have any allergies since they have been admitted before. DEPENDABLE SYSTEM FOR QUALITY CARE Evidence has shown that computerized decision support systems can improve patient safety. The data processing capacity of computers has been harnessed by a number of electronic systems designed to assist in clinical decision-making. These systems range from computerized reminders about preventive services to alerts about drug-drug interactions to computerized ventilator management. There are several examples of clinical informatics applications that have been shown to improve patient safety. • At LDS Hospital in Salt Lake City, Utah, a computerized decision support system with physician order entry (POE) reduced the incidence of adverse drug events related to antibiotic administration

by 75%. It also significantly reduced orders for drugs for which patients reported allergies and adverse effects that were caused by antibiotics. • At the Regenstrief Institute for Health Care in Indianapolis, Indiana, researchers demonstrated that automated computerized reminders increased orders for recommended interventions from 22% to 46%. At the Brigham and Women’s Hospital in Boston, Massachusetts, use of a POE system with decision support led to increased use of appropriate medications for high-risk clinical situations, such as an increase in the use of subcutaneous heparin to prevent venous thromboembolism from 24% to 47%. Medication errors were also reduced by 19% to 84%. These changes persisted throughout the 1- and 2-year follow-up periods. A 1998 systematic review that assessed the effects of 68 computer-based clinical decision support systems demonstrated a beneficial, though variable, impact on physician performance in 43 out of 65 studies (66%) and a beneficial effect on patient outcomes in 6 out of 14 studies (43%).

These examples illustrate that POE systems with decision support can help reduce medication errors, improve prescribing patterns and guide treatment decisions. Despite these successes, only a small number of health care systems in the United States have such systems in place. In addition, most of the work on IT and patient safety has occurred in the inpatient setting. Yet most of health care delivery occurs in non-inpatient settings, such as physician offices, urgent care centers, emergency departments, nursing homes, pharmacies, and home care, where IT penetration has occurred to an even lesser extent. Research and demonstrations projects are greatly needed in these settings. While recent innovations in information technology have been touted over the past several years, many of these applications have not been adequately evaluated in the health care arena. For example, wireless hand-held computers, such as personal digital assistants (PDA), offer great potential as portable communication tools that can provide information and decision support. In one study, these devices were shown to improve the detection and prevention of adverse events in an ICU setting. However, more research is needed in this area to evaluate their effects on important patient outcomes in various health care settings. Other technologies may also play a role in the patient safety arena. Medication bar codes and automated medication dispensers are being utilized in some health care settings to reduce errors. The use of scannable patient bracelets containing drug, allergy and other medical information has also generated interest. Such devices could help ensure the appropriateness of medications, blood products, and other therapeutics that are administered to patients. They could also be used to generate alerts about allergies, drug-drug interactions, and other potential problems before erroneous administration occurs. The Veterans Health Administration and Department of Defense have been national leaders in this area. Smart cards are electronic devices the size of credit cards that store and process medical information on a microprocessor chip. The Department of Defense has been a leader in the use of this technology. In much the same manner that ATM cards allow consumers to access banking services from virtually anywhere in the world, these smart cards would give patients a portable means of carrying their medical information, which could then be accessed electronically by providers or healthcare facilities at disparate locations. Interactive smart cards could also generate alerts about potential adverse events resulting from medication and other types of errors. While promising, this technology remains in development and has not been utilized or evaluated to a significant degree in the clinical setting. While clinical informatics has the potential to greatly improve patient safety and quality of care, much more work is needed in terms of implementation and evaluation of these technologies and their impact on important outcomes. Research is needed to evaluate IT tools that alert providers to information that may be critical to the provision of high quality care, develop strategies to address barriers to successful adoption of innovative IT applications, document the costs and resources associated with the IT applications, and evaluate transferability to other settings. NURSING MINIMUM DATA SETS The Nursing Minimum Data Set (NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations, settings, geographic areas, and time.

NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses standardized nursing terminology that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses. In 2002, NANDA relaunched as NANDA International in response to the broadening scope of its membership. NANDA International published Nursing Diagnosis quarterly, which became the International Journal of Nursing

Terminologies and Classifications in 2002.Other related international associations are AENTDE (Spanish), AFEDI (French language) and JSND (Japan)

The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Associationrecognized terminology, is included in the UMLS, and is HL7 registered. The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associate with the creation of a nursing care plan. The NIC consists of a standardized list which contains 433 different interventions. Each intervention is defined and the definition describes a set of activities a nurse performs in order to perform one of the interventions. Each of the 433 interventions is coded into a three-level taxonomic structure consisting of 27 classes and 6 domains. The taxonomic structure allows for easy selection of an intervention and to classify them by means of a computer. The NIC also allows for the implementation of a Nursing Minimum Data Set (NMDS). The terminology is an American Nurses' Associationrecognized terminology, is included in the UMLS, and is HL7 registered. The Omaha System is a standardized health care terminology consisting of an assessment component (Problem Classification Scheme), an intervention component (Intervention Scheme), and an outcomes component (Problem Rating Scale for Outcomes). Approximately 11,000 interdisciplinary practitioners, educators, and researchers use Omaha System for structured clinical documentation and analysis of secondary data. Omaha System users from Japan, Estonia, Hong Kong, New Zealand, Wales, Canada, The Netherlands, and the United States have presented at international Omaha System conferences. The Omaha System is integrated into the National Library of Medicine’s Metathesaurus, CINAHL, ABC Codes, NIDSEC, Logical Observation Identifiers, Names, and Codes (LOINC®), and SNOMED CT. It is registered (recognized) by Health Level Seven (HL7®), and is congruent with the reference terminology model for the International Organization for Standardization (ISO). It is being mapped to the International Classification of Nursing Practice (ICNP®). INFORMATICS THEORY

Informatics- is a science that combines a domain science, computer science, information science and cognitive science. Health care informatics-is the integration of healthcare sciences, computer science, information science, and cognitive science to assist in, address the study and management of health care information. It is a sub-discipline of informatics. The study of how health care data, information, knowledge and wisdom are collected, stored, processed, communicated and used to support the process of health care delivery to clients, providers, administrators and organizations involved in health care delivery. Nursing informatics- is the use of information technologies in relation to any nursing functions and actions of nurses. MODELS FOR NURSING INFORMATICS Definitions of Nursing Informatics – (information technology–oriented, conceptually oriented, and role-oriented definitions) Information Technology–oriented Definitions Scholes and Barber “the application of computer technology to all fields of nursing—nursing service, nurse education, and nursing research.” Ball and Hannah Nursing informatics was “those collected informational technologies which concern themselves with the patient care decision-making process performed by health care practitioners.” Any use of

information technologies by nurses in relation to the care of their patients, the administration of health care facilities, or the educational preparation of individuals to practice the discipline is considered nursing informatics. Saba and McCormick Nursing information systems are systems that use computers to process nursing data into information to support all types of nursing activities or functions. The use of technology and/or a computer system to collect, store, process, display, retrieve, and communicate timely data and information in and across health care facilities that administer nursing services and resources, manage the delivery of patient and nursing care, link research resources and findings to nursing practice, and apply educational resources to nursing education. Conceptually Oriented Definitions A shift from technology-focused definitions to more conceptually oriented definitions began during the mid 1980s. However, this approach did not gain acceptance until nearly 1990. Schwirian stressed the need for a “solid foundation of nursing informatics knowledge [that] should have focus, direction, and cumulative properties.” She emphasized the need for informatics research to be “proactive and model-driven rather than reactive and problem-driven.” Graves and Corcoran. A combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care. Graves and Corcoran discussed the need to understand “how clinical nurses structure clinical problems and how they ask questions of the information system.” These views accented the need to consider the clinical decision-making process in the design of information systems. With an understanding of how captured data are used in decision making, designers can create systems that better meet the needs of nurses during their clinical decision-making processes. The centrality of nursing practice in the Graves and Corcoran definition also supported the need for nursing informatics as a distinct specialty within health informatics. Although informatics nurse specialists use many of the same tools and processes as practitioners in other areas of informatics, the data, information, and knowledge have elements unique to nursing. Graves and Corcoran in effect narrowed the definition of nursing informatics, from the entire framework of nursing practice to the conceptual movement of data, information, and knowledge. This movement shifted the emphasis away from technology but also removed the context of nursing and de-emphasized the interrelationships among technology, nurse, and patients. Turley. His major contribution was the addition of cognitive science to a model comprising the original three sciences proposed by Graves and Corcoran. Cognitive science includes such topics as memory, problem solving, mental models, skill acquisition, language processing, and visual attention. These concepts can help informatics nurse specialists understand the decision-making and information processing done by nurses and, subsequently, assist in the creation appropriate tools to support nursing processes. Therefore, cognitive science is most helpful to informatics nurse specialists concentrating on informatics issues related to users, such as decision making and the construction of computer interfaces for nurses. Role-oriented Definitions The ANA expanded the previous definitions by incorporating the role of the informatics nurse specialist into the earlier Graves and Corcoran definition A specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, and research and to expand nursing knowledge. The purpose of nursing informatics is to analyze information requirements; design, implement and evaluate information systems and data structures that support nursing; and identify and apply computer technologies for nursing.

The second sentence addresses concepts that represent the life cycle of information systems, more commonly called the “systems life cycle.” This particular definition represents the first time concepts from an informatics method, the systems life cycle, appear in a definition. In 1994, the ANA modified their definition in an effort to legitimize the specialty and guide efforts to create a certification examination: Nursing informatics is the specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, research, and expansion of nursing knowledge. It supports the practice of all nursing specialties, in all sites and settings, whether at the basic or advanced level. The practice includes the development of applications, tools, processes, and structures that assist nurses with the management of data in taking care of patients or in supporting their practice of nursing. • The evolution of definitions for the specialty of nursing informatics will undoubtedly continue into the near future at least. Endeavors directed toward refining the definition of nursing informatics should address the following issues.

First, even in this amalgam of definitions, the role of patients is underemphasized. As technology has become more widely available, patients are taking a more active role in their health care. Therefore, definitions of nursing informatics will need to consider this increased involvement in a refinement of a definition for the specialty. Second, in the clinical setting, nurses are information integrators at the patient level. This close connection between nurse and patient in clinical settings has not been evident in past definitions, and the role of the nurse as information integrator has not been explicated. The role of nurses as they integrate data from and communicate data to other providers, such as other nurses, physicians and pharmacists, has not been highlighted. In a revised definition, nurses should be identified as information integrators among patients and other providers. Third, other salient elements and their inter-relationships need to be addressed in a revised definition —support for decision making by nurses, technology, and context. Fourth, the role of knowledge building through research is essential to include. This acknowledgment would begin to address the critical role of informatics research in current endeavors, such as evidenced-based practice, genomics, and neuroscience. Finally, a new definition needs to consider pertinent theories, concepts, tools, and structures that are useful to the informatics nurse specialist—information structures (taxonomies and other meaningful organization of information), information technology, and the communication of information. A Revised Definition of Nursing Informatics Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology. The role of the informatics nurse specialist is: To employ informatics theories, concepts, methods, and tools to analyze information and information system requirements; design, select, implement, and evaluate information systems, data structures, and decision-support mechanisms that support patients, nurses, and their human–computer interactions within health care contexts; and to facilitate the creation of new nursing knowledge. DATA, INFORMATION AND KNOWLEDGE - are identified as current metastructures or overarching concepts for nursing informatics with specific definitions. Data- are discrete entities that are described objectively without interpretation and would include some value assigned to a variable. Information- reflects interpretation, organization or structuring of data. It is the result of processing data. Data processing occurs when raw facts are transformed through the application of context to give those facts meaning or via the organization of data into a structure that connotes meaning.

Knowledge- emerges from the transformation of information. Knowledge is information that is synthesized so that relationships are identified and formalized. CLINICAL INFORMATION SYSTEM a. Planning phase -begins once an organization has determined that an existing need or problem may be filled or solved by the development or implementation of a CIS. Establishing the committee framework to research and make recommendations for the project is an important first step. -the committee generally includes representatives from the following areas:      Hospital administration/finance Nursing administration Medical staff Information systems department at director or manager level Major ancillary departments (laboratory, radiology, pharmacy, dietary, medical records and patient registration, patient accounting) Health information management (medical records) Legal affairs Outside consultants (as needed) Other appointed members (as needed)

   

The project team is led by an appointed project manager and includes a designated team leader for each of the major departments affected by the system selection, implementation or upgrade proposed.    Understand the technology and technology restrictions of a proposed system Understand the impact of intradepartmental decisions Make decisions at the interdepartmental level for the overall good of the CIS within the organization Become the key resource for their application

-the departmental teams       To thoroughly understand the department’s information needs To gain a full understanding of the software’s features and functions To merge the new systems capabilities with the department’s operations To assist in the system testing effort To participate in developing conducting end user education To provide a high level of support during the initial activation period of the new system

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During the planning phase, the information requirements necessary to solve the problem or accomplish the goal are assessed and information needs for selecting, implementing and upgrading a CIS including their implications are identified. It is the most critical phase in the selection of a system.

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The planning phase involves the following steps:   Definition of the problem/ goal statement Feasibility study (statement of objectives, environmental assessment, determination of information needs, determination of scope and timeframe, recommendations)

-then feasibility study seeks to answer the ff: -what is the real problem to be solved or goal to be met? -where does the project fit into overall strategic plan of the organization? -what specific outcomes are expected from the project? -what are the measurable criteria for determining project success from the above outcomes? -What are the limitations and risks? -What is the timing of the remaining phases of the project? -Who will be committed to implementing the project? -What are the estimated costs in finances and personnel time? -What is the justification for the project including the relationship between costs and benefits?

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Documentation and negotiation of project scope agreement Allocation of resources • • Present staffing workload Human resources (number, abilities and experience, percentage of dedicated time to the project) Present cost of operation Relationship of implementation events with nonproject events Anticipated training costs Space availability Current and anticipated equipment requirements for the project team

• • • • •

b. System analysis phase -fact finding phase where all the data requirements related to the problem defined in the project scope agreement are collected and analyzed to gain a sound understanding of the current system, how it is used and what is needed from the new system. Process analysis is foundational to the actual system design since it examines the objectives and project scope in terms of the end user requirements, the flow of information in daily operation and the processing of required data elements. Through the analysis effort, the individual data elements, interfaces and decision points of the project are identified.  Data collection o workflow document-assimilates the data collected into logical sequencing of tasks and subtasks performed by the end users for each goal or problem area

-departmental standards of care, ordering patterns, procedures, operating manuals, reports (routine, regulatory, year-end) and forms used day-to-day operations are collected. o Functional design document – overview statement of how the new system will work. It uses the workflow document as its base, adding critical documentation of the integration of each of the workflow documents to create a new system, implement commercial software application or upgrade a system. It outlines human and machine procedures, the input points, the processing requirements, the output from the data entry, and the major report to be generated from the new system. It provides programmers with a view of screens, linkages and alternate scenarios to accomplish a task.

Data analysis (data flowchart, organizational chart, model)

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Data review (feasibility study, workflow document, and functional specification) and provide recommendations to the committee. Benefits identification System proposal development – it sets forth the problems and goals and the requirements for the new systems overall design. It outlines the standards, documentation, and procedures for management control of the project and it defines the information required, the necessary resources, anticipated benefits, a detailed workplan, and projected costs for the new system. It furnishes the committee recommendations concerning proposed CIS. -the format: 1. 2. 3. Concise statement of the problems or goals Background information related to the problem Environmental factors related to problem: a. b. c. d. 4. 5. 6. 7. Anticipated benefits Proposed solutions Budgetary and resource requirements Project timetable Competition Economics Politics Ethics

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c.

The system design phase -the design details of the system and the detailed plans for implementing the system are developed for both functional and technical components of the system. • Functional specifications – uses the functional design document developed in the system analysis phase of a CIS and builds on the design by formulating a description of all system inputs, outputs and processing logic required to complete the scope of

the project. It further refines what the proposed system will encompass and provides framework for its operation.

Data manipulation and output – the departmental teams and users determine what the actual data will look like in its output form and gain consensus from departmental teams for the proposed design.

Technical specifications- technical personnel work closely with the project and departmental teams to ensure the technical components of the proposed system work in concert with technology and end user needs to assist in the development of the implementation plan.    Hardware (select hardware) Application software (develop software) Interface systems – defines the programs and processes required to transmit data between two disparate systems. (Ex. Health Level 7 (HL7) interface, from registration system data is sent via a separate interface system to other clinical component systems in their respective unique format requirement like laboratory, pharmacy, appointment and scheduling, documentation system, radiology, critical care system and patient accounting) -management of all interfaces to the separate clinical systems occurs through a single source, the interface engine.  Conversions – conversion of data from legacy system to new system

Implementation planning         Personnel Timeframe Costs and budgets Facilities and equipment required Development or implementation of tasks Operational considerations Human-computer interactions System test plan

d. The testing phase – The system whether newly developed or commercially available must be
tested to ensure all data are processed correctly and the desired outputs are generated. Testing verifies that the computer programs are written correctly and ensures that when implemented in the program (live) environment, the system will function as planned.

e. Document system – the preparation of documents to describe the system for all users is an
on-going activity with development of the documentation is occurring as the various system phases and steps are completed. Documentation should begin with the final system proposal. Several manuals are prepared:

User’s manual – highlights how to use the system and describes what outputs the system can produce. Reference manual – used by the project team members to understand how the system works. It describes what data are input, how databases (files and tables) process the data and the mechanisms used to generate outputs. Operator’s maintenance Manual- enables operators to keep the system up and running by providing the functional and technical specifications needed by the system. It helps operators understand how the system is developed, how it operates and how it can be maintained, updated and repaired.

f. The training phase – to train the end users on how to use the system properly.
• The project team and selected members of the departmental team receive training from the developers or vendors. This training details the databases, processing logic and outputs of all system’s features and functions. End user training takes place once the departmental and project teams have finished profiling the system to meet the functional and technical specifications developed and functional testing has been completed. End user training stresses how the user will complete his workflow using the new system.

g. The implementation phase – organizes all the steps into a detailed plan describing the
series of events required to begin using the system in the production or live environment and details the necessary computer and software maintenance operations required to keep the system running.

h. The evaluation phase –describes and assesses in detail the new system’s performance.
Using the criteria established in the planning and system design phases, the evaluation phase summarizes the entire system, identifying both the strengths and weaknesses of the implementation process. It often leads to system revisions, then better system.

PRACTICE APPLICATIONS

CRITICAL CARE (critical care units) is the nursing specialty that deals with human responses to life threatening problems. It is a multidisciplinary healthcare specialty that cares for patients with acute life-threatening illness or injury. IT capabilities and applications in the critical care settings • • • • • • Process, store and integrate physiologic and diagnostic information from various sources. Present deviations from present ranges by an alarm or an alert Accept and store patient care documentation in a lifetime clinical repository Trend data in a graphical presentation’ Provide clinical decision support through alerts, alarms and protocols Provide access to vital patient information from any location both inside and outside of the critical care setting Comparatively evaluate patients for outcomes analysis Present clinical data based on concept-oriented views (organize data by patient problem or by system)

• •

a. Physiologic monitoring systems:  Hemodynamic monitors –advanced hemodynamic monitoring systems allow for calculation of hemodynamic indices and limited data storage. It can be invasive or non-invasive. o o o o o o o o o o o o  Measure hemodynamic parameters Closely examine cardiovascular function Evaluate cardiac pump output and volume status Recognize patterns (arrhythmia analysis) and extract features Assess vascular system integrity Evaluate the patient’s physiologic response to stimuli Continuously assess respiratory gases (capnography) Continuously evaluate blood gases and electrolytes Estimate cellular oxygenation Continuously evaluate glucose levels Store waveforms Automatically transmit selected data to a computerized patient database

Arrhythmia monitors – computerized monitoring and analysis of cardiac rhythm have proved reliable and effective in detecting potentially lethal heart rhythms. System types: o Detection surveillance and diagnostic – the computer has been programmed with the criteria of the normal and surveys and may include alarms when there is deviation.

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Interpretive – interprets the data that predetermined diagnostic specifications.

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b. Mechanical ventilators: A mechanical ventilator is a machine that generates a controlled flow of gas into a patient’s airways. Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within the machine, and delivered to the patient using one of many available modes of ventilation.

c.

Critical care information systems: -a CCIS is a system designed to collect, store, organize, retrieve and manipulate all data related to care of the critically ill patient. It is focused on individual patients and the information directly related to the patients’ care. It is for the organization of a patient’s current and historical data for use by all care providers in patient care.

Components of: o Patient management – admission, transfer and discharge data; prognostic scoring systems (evaluations scores); schedule patient care activities, treatment and diagnostic testing. Vital sign monitoring Diagnostic testing results Clinical documentation to support process of physical assessment findings – patient assessment flowsheets (maybe organized according to body system like neurologic flowsheet); all disciplines (nurses, doctors, therapists, etc.) can document assessment findings into the CCIS; alerts are automatically generated for patients high risk for fall, pressure ulcers and others); automatic calculation of physiologic indices can be performed. Decision support – CCIS can provide alerts and reminders to guide care in accordance with evidenced-based guidelines. (ex. Prompts to guide caregivers on required documentation; alerts on adherence to protocols such as restraint management, pain management and ventilator weaning) Medication management – use of barcode scanning and electronic medication administration record (eMAR); calculations of intravenous meds dosages, IV flowrates, hyperalimentation and total intake and output schedules are among the calculations available depending on the system, values may be part of patients database or ogffered as off line calculator. Interdisciplinary plans of care- multidisciplinary documentation and planning of patient care; flowsheets incorporating required treatments and interventions; workflow management solutions for numerous simultaneous processes of patient care; Provider order entry- electronic entry and communication of patient orders, combined with rules and alerts related to evidence-based care.

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COMMUNITY HEALTH APPLICATIONS - a synthesis of nursing practice and public health practice applied to promote and preserve health of populations.

Home health care – the provision of preventive, therapeutic, restorative and supportive health care in the home. Public health – the Institute of Medicine (IOM) defines public health as coordinated effort at the local, state and federal levels whose mission is fulfilling society’s interest in assuring conditions in which people can be healthy. Focus on: • Preventing, identifying, investigating and eliminating community health problems • Assuring that the community has access to competent personal healthcare services • Educating and empowering individuals to adopt more healthy behaviors Data Sets – a uniform data set is a minimum set of items of information with uniform definition and categories concerning the specific dimensions of the service or practice setting that meets the essential information needs of multiple data users within the scope of the service or practice setting. Selected data sets: the National League for Nursing (NLN) developed one of the first prototypes for a basic minimum data set for CHN even though it is no longer being used.

Uniform data set for homecare and hospice – the National Association of Home Care (NAHC) Resource Committee initiated a task force to develop a uniform data set for Home Care and Hospice to achieve a standardized comparable home care and hospice data. The data set is organized into two major categories of organizational and individual level data elements.

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Organizational – description of the organization, services, aggregate utilization and financial and personnel data. Individual – demographic, clinical, service, and utilization data for clients/patients.

Outcome and Assessment Information Set (OASIS) – this is a group of items that represents the core items of a comprehensive assessment for an adult home health patient and forms the basis for measuring patient outcomes for purposes of Outcome-Based Quality Improvement (OBQI). Outcome-Based Quality Improvement (OBQI) – it includes two components, Outcome analysis and outcome enhancement. • Outcome analysis- begins with homecare agencies transmitting the OASIS data to central repository which then produces outcome, case mix and adverse event reports on an annual basis. Outcome enhancement – allows agencies to use data for OBQI activities at the agency level and assist Medicare survey and certification process by providing specific information regarding the individual Home Health Association’s (HHA) performance.

Health Plan Employer Data and Information Set (HEDIS) -a set of standardized performance measures designed to ensure that purchasers and consumers have the information for reliably comparing the performance of managed healthcare plans. There is also a standardized survey of consumers’ experiences that evaluates plan performance related to customer service, access to care, and claims processing. Vocabulary languages -are validated clinical reference languages, taxonomies or terminologies that make health care knowledge more usable and accessible. The language, vocabulary or taxonomy enables a consistent way of capturing, sharing and aggregating health data across sites of care. The vocabulary serves as a vehicle to format messages that are exchanged between computer system and the coding and classification scheme used within the messages, for messages to have agreement in syntax so that individual data can be structured in a common way. The two most common nursing vocabularies or taxonomies in use for CHN:

Clinical Care Classification (CCC) system- a standardized language/vocabulary consisting of two interrelated taxonomies – the CCC of nursing diagnoses and the CCC of nursing interventions (both Version 2.0). The CCC is designed to document, code, and classify for computer-processing care in any clinical setting by any health care provider using a standardized framework. They are used to electronically track and analyze patient care overtime across settings, population groups, and geographic locations.

CCC nursing diagnoses consists of 182 (59 major and 123 subcategories) nursing diagnoses/patient problems that use three modifiers: improve patient’s condition, stabilize patient’s condition and support patient’s deteriorating condition. These modifiers depict 546 terms used to measure the actual outcomes of the nursing diagnoses/ patients problems. The CCC nursing interventions consists of 198 (72 major and 126 subcategories) nursing interventions or services which use four modifiers: assess/monitor, care/perform, teach/instruct and manage/refer to depict the type of interventions. These modifiers depict 7792 unique interventions used to treat the nursing diagnoses/patients problems. The CCC uses the nursing process for its conceptual model with different labels for its six phases – care components (assessment), diagnoses/problems (diagnosis), expected outcome (outcome identification), nursing interventions (planning), type action (implementation) and actual outcome (evaluation). CCC taxonomies are registered as a HL7 language integrated to LOINC (logical observations, identifiers, names and codes), SNOMED CT (systematized nomenclature of human and veterinary medicine reference terminology), alternative medicine ABCcodes and UMLS (unified medical language system) of the National Library of Medicine (NLM). They have been approved and evaluated by several standards organization.

Omaha System – is a researched based comprehensive taxonomy designed to generate meaningful data following usual or routine documentation of client care. It consists of three components – the problem classification scheme, intervention scheme and problem rating scale for outcomes. The system provides a method for linking clinical data to demographic, financial, administrative and staffing data. The problem classification scheme is a vocabulary for CHN developed by Visiting Nurse Association (VNA) of Omaha in 1970. This vocabulary is consistent with the general and comprehensive practice of CHN. Included in the system are 44 nursing problems that were arrived at empirically from the practice of the community health nurses employed by the visiting nurse agency. The problems are organized by the four broad domains addressed by community health nurses – environmental, psychosocial, physiologic and health related behaviors. Each problem is described by a list of signs and symptoms. The problem may be referenced as health promotion, potential, or deficit/impairment/actual. The patient may be defined as individual or family. The system also includes terms for interventions. The intervention scheme is an organized framework of community nursing activities designed to address specific nursing diagnoses using four broad categories of interventions – health teachings, treatments, case management and surveillance.

Community Health Intensity Rating Scale (CHIRS) – was a prototype classification tool that included 15 parameters that represented the same four home health domains as the Omaha System. Each of the 15 parameters included patient profiles to illustrate the extent of nursing input required for patient care for four levels of care contained within each parameter, for a total of 60 profiles. A profile was selected for each parameter and then the rater implicitly integrated these into a categorical rating for the patient’s resource requirements. The ratings were as follows:    Level Level Level Level 1-minimun requirement 2-moderate requirements 3 – major requirements 4- extreme requirements

Community Health Systems – connotes those computerized IT systems specifically developed and designed for use by community health agencies, local, and state health departments, community programs and services. Community health systems address the broad areas of – healthcare programs, agencies, and settings. They support health promotion and disease preventive programs, statistical information required by state/local health department programs and funding information for federal block grants, categorical grants or other grant programs. The following are some of the typically used systems in community health systems: • Categorical systems – designed to support data processing and tracking specific programs such as cancer detection, MCH immunization or family planning; to collect longitudinal data for a specific disease condition that can be used for national databases for tracking incidence and prevalence of disease conditions. Categorical program systems generally count, track and identify the health status of registered clients.

Screening programs – used to detect individuals afflicted with a specific disease or predisposing condition. These programs uses computer systems to collect important health information that may be mandated by federal, state or local regulations. Registration systems – Client Registration Information Systems (CISs) are designed to identify state/local residents/clients eligible for CHN services in clinics and homes. These systems consist of an online communication network with terminals located in each district offices that are linked to a central computer facility used to collect, store and process all data. The centralized registry can then be accessed from the district/local units prior to providing services. Management information systems – focus on the management of statistical and operational needs of the agency and professionals. It can also provide framework for collecting and reporting statistical as well as financial data needed for the management of health personal/client and programs. Statistical reporting systems – are community health computer applications that have been developed to collect and process statistical information primarily for state/local health departments such as epidemiologic data and immunization data. Public health information system – the development of a public health information network (PHIN) will enable consistent exchange of response, health, disease tracking data between public health partners through defined data and vocabulary standards. The five key components include detection and monitoring, analysis, information resources, and knowledge management, alerting and communications and response. National Electronic Disease Surveillance System – to promote the use of data and information system standards to advance the development of efficient and integrated surveillance systems at the federal, state, and local levels. It is designed to (1)detect outbreaks rapidly and monitor the health of the nation, (2) facilitate the electronic transfer of appropriate information from clinical information systems in the healthcare system to public health departments, (3) reduce provider burden in the provision of information, and (4) enhance the timeliness and quality of information. Special purpose systems –developed to collect statistical data for administering a specific program (rather than an agency) regardless of what type of agency offers the program. Stand alone systems are designed to collect and summarize management data on services in clinics, schools and homes. These systems provide the statistics needed to obtain funds from federal, state, or local units for categorical problems and/or block grants. Special study systems generally require a specially designed computer applications, studies that collect large volumes of data require computer processing using standard statistical software programs or specially designed computer processing models. School health systems - computerized systems have emerged to improve data collection and monitor and evaluate health of school- age students and school personnel. These systems can be individual school-based or district-based allowing for collecting aggregate data about an educational district.

Home Health Information Systems – home health systems are designed to support home he health care, hospice and private duty programs provided by Home Health Agencies (HHA) such as Visiting Nurses Association (VNAs), nonprofit HHAs and hospital-based programs. These systems collect and process data and include applications on clinical service delivery, integrated financial functions, scheduling packages, decision support functions, payroll, personnel management, accounts payable, billing functions, general ledger, financial reporting and statistical reporting capabilities. Telemedicine Systems – communication telemedicine systems link patients homes to healthcare facilities and healthcare professionals, home care workers to their supervisors and patient and families with community resources. This allow for reduction of inconvenient and expensive visits to health care providers and omit unnecessary visits to healthcare facilities. Telemedicine devices: • Texas Telemedicine Project using a two way interactive video major urban centers with health professionals in rural areas for diagnosis and consultation. Home assisted nursing care network (HANC) is a programmed computer stationed in patients’ homes. The unit is a voice activated, 3.5 ft. tall robot with a video screen. A central nursing

station is linked to the home system by telephone lines. HANC can walk patients through a dress change, assess the condition of an IV site, or provide reminders for taking medications. Community health network system – is an innovative ambulatory care system specially developed to provide services by computer. Computer terminals are placed in homes of “heavy users of health care” such as families with young children, pregnant women, disabled and the elderly. The system allows the subscribers to telephone for assistance and guidance on services offered via the terminal. The system performs actions but not necessarily diagnoses: • • • • Download the patient record from the hospital to the home database Enters series of questions about symptoms using expert system logic until the pathways are concluded Track self care and, depending on the responses to questions, call or make an appointment with a clinician. Provide additional information on the condition if self care is chosen to assist the client to resolve the problem.

Home high-tech monitoring systems - are using computers to link patients at home to health care facilities. Monitoring devices that transmit vital signs and other critical data are used in the home to conduct postsurgical checkups for example. They allow healthcare providers to monitor the progress of their patients. It allows transmission of healthcare information being used not only for diagnosis and treatment but also prevention. The data is then reviewed by health care providers in the central station and are alerted for abnormal assessments/parameters for a particular patient. Another monitoring device is a remote defibrillator that allows hospitals to diagnose and resuscitate a homebound patient who had suffered a cardiac arrest. This transtelephonic defibrillator device located in home called briefcase is linked to the hospital base unit. Sophisticated telemetry devices such as digitized x-ray and ECG, electronic stethoscopes and interactive video equipment are also using telecommunications technology to enable specialists to examine patients in remote clinics. Another is alert systems that allow the homebound to signal for help in an emergency. Educational technology systems – provide communication linkages, information access, and educational materials that meet the clients need to reach beyond their environment. These systems may also offer screening for compliance with health prevention standards and linkages to education AMBULATORY CARE SYSTEMS -as a response to increasing costs of providing health care, the healthcare industry has moved away from the expensive inpatient acute care environment to caring for clients in various ambulatory care settings. They include ambulatory clinics and surgery centers, single and multi-specialty group practices, diagnostic laboratories, health maintenance organizations, independent physician associations, birthing centers and college and university health services. Other organizations that serve the ambulatory population are faculty medical practices, community health centers, prison health centers, office-based surgery centers and practices, pain management clinics and many more. -ambulatory care information systems usually computer-assisted are designs to store, manipulate and retrieve information for planning, organizing, directing and controlling administrative and clinical activities associated with the provision and use of ambulatory care services and facilities. The applications needed in the ambulatory environment are similar to those required in in-patient arena. Registration, billing, accounts receivable, accounts payable, patient and staff scheduling and managed care functionality are the major application areas. Financial benefits • Cost effective and timely bill submission process resulting in decreased days in accounts receivable and the reduction of rejected claims.

Administrative benefits • Reduction in the size of the record room, reduced to time spent finding and delivering charts, increase in the privacy of data, formats that are legible and comply with legal regulations, and the promotion of quality assurance and improved patient satisfaction. Ability for home access by physicians and nurse practitioners, alerts for incomplete data and integration of clinical data.

Clinical benefits • Can provide a problem list, automated, automated ambulatory care provider order entry (ACPOE), a medication record, vital signs, progress notes, results from the laboratory and radiology departments, flow sheets, growth charts, immunization records, medication allergies,

profiles, alerts and reminders, and a follow-up system. Other applications for the clinical area can encompass a clinical decision support system, ePrescribing and evidence based medicine. Regulatory requirements -systems must support the resource based relative value scale (RBVS) and the relative value unit (RVU). In this system, each physician’s current procedural terminology (CPT) code has a relative value associated with it. The payor will pay the physician on the basis of a monetary multiplier for the RVS value. -the ambulatory care arena just like other health care requires data in order to manage care. The Health Care Portability and Accountability Act of 1996 requires 6 code sets. Behind the scenes, a database must be maintained of all current coding schemes used for the ambulatory environment. These include:


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Current Procedural Terminology 4th edition (CPT) The Ninth Revision of the International Classification of Diseases (ICD-9-CM) The Healthcare Common Procedure Coding System (HCPCS) The National Drug Code (NDC) managed by FDA Code on Dental Procedures and Nomenclature

The role of nurse using informatics concepts in ambulatory arena -user of the data contained in automated systems, to take the data and put it together in meaningful ways, making information. -reports are generated that can be used in better management of the health of the patient, managing the administrative aspects of the practice, generating financial information, or in conducting research. -a nurse may be involved in the selection of automated systems based on a needs assessment of the environment. -the ambulatory nurse can be instrumental in the implementation of an automated system whether administrative, financial or clinical. Member associations involved in ambulatory care (org description and logo) -the American Academy of Ambulatory Care Nursing (AAACN) is a member organization specifically for nurses. It offers networking opportunities for the membership by geographic location through local networking groups and by specialty practice through special interest groups (SIGs). One SIG for informatics is working to develop an ambulatory care data set for nursing. It also represents ambulatory practice to other political advocacy organizations, agencies and in federal and state legislative arena. -the American Medical Informatics Association (AMIA) has physicians and nurses amongst the membership. Working groups include the Primary Care Informatics Working Group. -the Medical Group Management Association (MGMA) is composed of physicians in group practice nationwide. -the Society of Ambulatory Care Professionals is associated with the American Hospital Association, an organization of management professionals across the continuum of health care services, including outpatient, ambulatory and home health care in hospital and freestanding settings. -the Federated Ambulatory Surgery Association (FASA) is a non-profit association representing the interests of ambulatory surgery centers in the USA. It represents the physicians, nurses, administrative staff and owners industry before the media, Congress, state legislatures and regulatory bodies. -the American Association of Ambulatory Surgery Centers (AAASC) is a member organization that promotes advocacy at the national level through relationships with the CMS and congress, networking and educational opportunities. -the Association of Ambulatory Behavioral Healthcare (AABH) is an international organization of ambulatory mental healthcare providers dedicated to the delivery of high quality psychiatric and chemical dependency treatment with continuum of care.

-the American Health Information Management Association (AHIMA) is a membership organization of health information management professionals. -the Healthcare Information Management Systems Society (HIMSS) has formed an Ambulatory Care Committee, the HIMSS Ambulatory Care Initiative was created in response to trends such as aging population, increasing prevalence of chronic diseases, and development of minimally invasive procedures that can be performed without hospitalization. Accreditation organizations: Accreditation Association for Ambulatory Health Care (AAAHC) is a nonprofit organization to develop standards and conduct a survey and accreditation program. COLA, a nonprofit physician directed and national accrediting organization to promote excellence in medicine and patient care through programs of voluntary education, achievement and accreditation. The National Committee for Quality Assurance (NCQA) is a private, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans. The Joint Commission on Accreditation of Healthcare Organization (JCAHO) publishes Management of Information Standards for Ambulatory Care that are yearly updated consistent with HIPAA.

INTERNET TOOLS FOR ADVANCED NURSING PRACTICE eCLINICALLOG The eCLINICALOG is part of an educational strategy, initially designed to build data entry, analysis and synthesis skills in nurse practitioner students. It becomes relevant to undergraduate education as well. Like other logs, eClinicalog started out as a paper and pencil format. Nurse practitioner students used logs to track the number of patients seen in clinical practical and record basis demographic data, medical diagnoses, and medications prescribed. It is also a useful pedagogic tool. It guides students through an informatics skill building and refinement process and assists professional development. Its successful use indicates that Internet applications are not just adjuvant educational tools but an integral part of the clinical learning process. It is currently an electronic data base which addresses issues of retrievability, familiarity, availability, student acceptance, curricular congruence and contribution to the discipline. It also includes HIPAA principles as well. Even content thought to be clinically oriented was updated as the clinical log evolved to be more encompassing. The eClinicalog is a necessary tool with the inclusion of electronic and Web-based tools to facilitate student learning and curricular development. EMERGENCY PREPAREDNESS AND RESPONSE Decision Support Systems – to develop a computer simulation model for city wide response planning for mass prophylaxis and vaccination during bioterrorist attacks and other public health emergencies. Syndromic surveillance – IT systems can aid intensively in detection of a disease outbreak before the actual disease or mechanism of transmission is identified. Example is the Real-time Outbreak Disease Surveillance (RODS) system that provides early warning of possible infectious disease outbreaks caused by bioterrorism or other public health emergencies. Helping clinicians respond – it contributes in providing training and education modules to teach healthcare professionals to identify various biologic agents. A system can also allow real-time transmission of clinical impressions and symptoms, which will aid in bioterrorism surveillance. Volunteers organization – used to organize bulk volunteers, educate them and how tasks are given. VENDOR APPLICATIONS -vendors are delivering more robust and tightly integrated clinical solutions that better address the needs of all care providers for more coordinated, streamlined patient care delivery.

Unlike with earlier systems that primarily automated the paper chart and basic patient care processes, vendors are now expected to deliver “next generation” clinical applications that: • Support multi and interdisciplinary care with all provider orders, care plans, and notes online and integrated in a common patient-centric patient record. Promote data integrity via data validity checks and embedded tools. Ex. Calculations Provide ready access to internal standards. Ex. Policies and procedures, drug databases, and reference guides Collect workload management data as byproduct of clinical documentation including deriving prospective acuity data from orders and retrospective acuity data from clinical documentation. Support productivity management, staffing and budgeting activities. Support process and outcomes monitoring, management, and continual improvement via standard reports and database mining. Support charge capture, supply management and inventory reconciliation. Ex. Replenishment of supplies and medications as byproduct of clinical documentation. Support for medical, disease and population management.

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(Case flow diagram) Key clinical system nursing and multi-disciplinary care components • • • • • • • • • Patient Access Admission Assessments Diagnosis/Problems Nursing and Multidisciplinary Orders and Plans of Care Integrated Plans of Care Kardex Workplans/tasklists Results Clinical Documentation Electronic Nursing Documentation Clinical documentation and practice are integrally linked – one being a reflection of the other. Collectively, allied health, nursing, and physician documentation come together to tell the patient’s story. Documentation, whether electronic or paper, must provide a record of the patient’s needs, care provided, and patient outcomes. Electronic interdisciplinary clinical documentation will: o o o o o o o o o Create a seamless integrated database of patient care information across the continuum of care Chronicle all aspects of care from health team members Capture the judgment and critical thinking used in professional practice Support UHN’s strategic goals for best practice, clinical decision making, patient safety, knowledge development and evidence-based practice Support integrated documentation and patient centered care Provide a corporate Documentation Standard Support electronic structured documentation to fulfill the dependencies of the Clinical Decision Support program Meet regulatory standards as well as organizational, government, and clinical specialty standards Support the exchange of information between disciplines

Discharge Summaries

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Summary Reports Outcomes Variance Reports

Compiled By: FjCaday2011

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