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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.

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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)

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Physiologic monitoring systems:

Hemodynamic monitors ²advanced hemodynamic monitoring systems allow for calculation of hemodynamic indices and limited data storage. It can be invasive or non-invasive. Arrhythmia monitors ² computerized monitoring and analysis of cardiac rhythm have proved reliable and effective in detecting potentially lethal heart rhythms.

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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.

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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 CCIS: Patient management € Vital sign monitoring € Diagnostic testing results € Clinical documentation € Decision support € Medication management. € Interdisciplinary plans of care € Provider order entry
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a synthesis of nursing practice and public health practice applied to promote and preserve health of populations.

Home health care ² the provision of preventive, therapeutic, restorative and supportive health care in the home. € Public health ² 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:
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¾ Preventing, identifying, investigating and eliminating community health problems ¾ Assuring that the community has access to competent personal healthcare services ¾ Educating and empowering individuals to adopt more healthy behaviors

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Data Sets ² 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: ¾ Uniform data set for homecare and hospice ² 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.
x Organizational ² description of the organization, services, aggregate utilization and financial and personnel data.

x Individual ² demographic, clinical, service, and utilization data for clients/patients.

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Outcome and Assessment Information Set (OASIS) ² 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) ² it includes two components, Outcome analysis and outcome enhancement.
¾ Outcome analysis ¾ Outcome enhancement

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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.

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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:
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Clinical Care Classification (CCC) system- a standardized language/vocabulary consisting of two interrelated taxonomies ² 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 computerprocessing 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.

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Omaha System ² is a researched based comprehensive taxonomy designed to generate meaningful data following usual or routine documentation of client care. It consists of three components ² 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.

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Community Health Intensity Rating Scale (CHIRS) ² 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: x x x x Level 1-minimun requirement Level 2-moderate requirements Level 3 ² major requirements Level 4- extreme requirements

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Community Health Systems ² 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 ² 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 € Screening programs € Registration systems € Management information systems € Statistical reporting systems € Public health information system € National Electronic Disease Surveillance System € Special purpose systems € School health systems

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Home Health Information Systems ² home health systems are designed to support home 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.

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Telemedicine Systems ² 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.

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Community health network system ² is an innovative ambulatory care system specially developed to provide services by computer. Computer terminals are placed in homes of ´heavy users of health careµ 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:
¾ Download the patient record from the hospital to the

home database ¾ Enters series of questions about symptoms using expert system logic until the pathways are concluded ¾ Track self care and, depending on the responses to questions, call or make an appointment with a clinician. ¾ 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. 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.
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Sophisticated telemetry devices such as digitized xray 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.
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Educational technology systems ² 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

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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.

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.
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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 followup system. Other applications for the clinical area can encompass a clinical decision support system, ePrescribing and evidence based medicine.

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Regulatory requirements 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:
¾ Current Procedural Terminology 4th edition (CPT) ¾ The Ninth Revision of the International Classification

of Diseases (ICD-9-CM) ¾ The Healthcare Common Procedure Coding System (HCPCS) ¾ The National Drug Code (NDC) managed by FDA ¾ Code on Dental Procedures and Nomenclature

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The role of nurse using informatics concepts in ambulatory arena
¾ user of the data contained in automated systems, to take the data and put it together in meaningful ways, making information. ¾ 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. ¾ a nurse may be involved in the selection of automated systems based on a needs assessment of the environment. ¾ the ambulatory nurse can be instrumental in the implementation of an automated system whether administrative, financial or clinical.

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Member associations involved in ambulatory care ¾ -the American Academy of Ambulatory Care Nursing (AAACN) ¾ -the American Medical Informatics Association (AMIA) ¾ -the Society of Ambulatory Care Professionals I ¾ -the Federated Ambulatory Surgery Association (FASA) ¾ -the American Association of Ambulatory Surgery Centers (AAASC) ¾ -the Association of Ambulatory Behavioral Healthcare (AABH) ¾ -the American Health Information Management Association (AHIMA) ¾ -the Healthcare Information Management Systems Society (HIMSS) Accreditation organizations: ¾ Accreditation Association for Ambulatory Health Care (AAAHC) ¾ COLA ¾ The National Committee for Quality Assurance (NCQA) ¾ The Joint Commission on Accreditation of Healthcare Organization (JCAHO)

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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.

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Decision Support Systems ² 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 ² IT systems can aid intensively in detection of a disease outbreak before the actual disease or mechanism of transmission is identified. Example is the Realtime 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 ² it contributes in providing training and education modules to teach healthcare professionals to identify various biologic agents. A system can also allow realtime transmission of clinical impressions and symptoms, which will aid in bioterrorism surveillance. € Volunteers organization ² used to organize bulk volunteers, educate them and how tasks are given.
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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 generationµ clinical applications that: ¾ Support multi and interdisciplinary care with all provider orders, care plans, and notes online and integrated in a common patient-centric patient record. ¾ Promote data integrity via data validity checks and embedded tools. Ex. Calculations ¾ Provide ready access to internal standards. Ex. Policies and procedures, drug databases, and reference guides

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¾ Collect workload management data as byproduct of clinical

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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.

Key clinical system nursing and multi-disciplinary care components
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Patient Access Admission Assessments Diagnosis/Problems Nursing and Multidisciplinary Orders and Plans of Care Integrated Plans of Care Kardex Workplans/tasklists Results Clinical Documentation Discharge Summaries Summary Reports Outcomes Variance Reports

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