What is the greatest significance to health care when an information system lacks interoperability quizlet?

financial barriers, physician resistance, loss of productivity, work flow changes, reduced physician-patient interaction, usability issues, integration w other systems, quality reporting issues, lack of interoperability standards, legal aspects, inadequate proof of benefit, patient safety

clinical results, images, documents, clinical summaries, financial info, medication data, performance data, case management, public health data, case management, referral management

name, location except for initial 3 digits of zip code, all elements of dates, phone numbers, facsimile numbers, email,ssn, med record #,healthcare benficiery #s, account#, license#, license plate#, device identifier and serial #s, URLs, IP address, biometric identifiers, full face photographs, any other unique identifying number

CDSS, secure messaging, an interface w practice management software, managed care module, referral management feature, retrieval of lab and xray med history reports electronically, CPOE, electronic patient encounter, multiple ways to input info, remote access from office, electronic prescribing, PACS, knowledge resources, public health reporting, generate quality reports, scan in text or OCR, ability to perfrom E&M determination for billing, security and privacy w HIPPA, CCD and CCR

Sets with similar terms

No alignment on terminology standards for nursing content definition. Therefore, patient data cannot be shared across care settings.

Demand for customized content does not allow for standardization of the EHR.

Expensive and resource-intensive to map local content to reference terminologies

Standardized terminologies have licensing fees for use in order to provide support to the customer. Those without licensing fees might not have the resources for routine maintenance and updates to the terminology.

Lack of documentation of nursing data in the EHR related to the lack of adoption of the terminologies, high patient workload, and poor design. Some of the EHR designs for nursing were based upon the paper-based system.

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Terms in this set (33)

Define healthcare information system

-an information system used in healthcare
-combines clinical information systems (directly support care, may stand alone, exchanges data among systems) and administrative systems (same but indirectly support care)

Explain the purpose of clinical decision support system and provide some examples

-support healthcare practitioners in making patient-care decisions
-enable integrated workflows, provide assistance at the time of care and offer care plan recommendations
-EBP, entire care team (including pt), use of EHR and other resources

Explain the function of computerized provider (or practitioner) order entry (CPOE)

-facilitates process of selecting scripted orders
-immediately shares the order with other health professionals to dispense, schedule, and deliver services to pts

Describe the functions of smart technology, especially focus on benefit for clinicians

-send real-time messages to all of the areas required during patient visit
-used by providers to documents visits, order medications while checking alerts for errors, schedule appointments, and generate bills

For clinicians...
-increases efficiency and communication between providers
-permits documenting tasks on the mobile computer system in pt's room
-handles alerts
-barcode scanning capability

For pts and families...
-decreased hospital wait times
-pts can get things they need for comfort through mobile device
-pts can select education materials
-electronic monitoring of vs
-care plan posted for pt viewing

Define administrative information system and its subsystems

Definition: indirectly support pt care, individual systems may stand alone, goal is data exchange amongst systems (hospital IT)
Subsystems:
-registration and scheduling systems
-patient acuity/staff scheduling systems
-financial systems
-risk-management systems
-payroll and human-resources systems
-quality assurance systems
-contract-management systems

Understand the information on the costs of maintaining functional HISs

-implementing and maintaining computer systems is very expensive
-they must be upgraded every two to three years with new software and hardware
-functionality will need to be added and interfaced with the current system

With older, overloaded systems, down time is a possibility...
-the system is then inaccessible
-it may be necessary to revert to documenting on paper until the system comes back up
-when the system does come back, there may be duplicate orders and documentation (on paper, and within the system)

Identify the functions of Laboratory- information systems (LISs)

-receive requests, schedule tests, and track specimen collection and trajectory
-permit the display of values over time to show trends and ranges
-notify practitioner of critical values, and document the time of notification

Differentiate between electronic health record (EHR), electronic medical record (EMR), shared electronic health record (SEHR), electronic health record system (EHRS), and personal health record (PHR)

EHR- a database of an individual's healthcare data during healthcare encounters
EMR- an earlier form of the EHR
SEHR- an electronic record system that allows clinicians to access a patient's data and information from the patient's EHR from different facilites
EHRS- a database management software enabling the many functions needed to create and maintain an EHR
PHR- a collection of patient data controlled by thee patient and accessible by the patient and providers

Recognize the relationship between Meaningful Use and the adoption of the EHR

-the use of EHR technology in a meaningful matter
-Medicare and Medicaid have EHR incentive programs, involving incentive payments to hospitals and healthcare professionals, in which all providers are required to participate

Having EHR systems that meet MU criteria are able to...
-improve the quality of care in patient populations
-improve efficiency by eliminating redundancies and automating tasks
-decrease spending in areas where information can easily be accessed versus having to repeat diagnostic tests and procedures

Discuss benefits associated with an EHRS-focus on benefits for healthcare providers & consumers

For HC providers...
-improved eligibility for reimbursement
-simultaneous record access by multiple users and promotion of interdisciplinary care
-previous encounters may be accessed easily
-faster chart access, eliminating waiting for old paper records to be located and delivered from the medical records dept.
-reduced liability
-improved efficiency for billing
-more comprehensive medical information
-enhanced ability to meet regulatory requirements such as the physician quality reporting initiative
-supports pay-for performance bonuses

For consumers...
-decreased wait time for treatment
-improved access and control over health information
-quicker turnaround time for ordered treatments
-alerts and reminders for upcoming appointments and scheduled tests
-increased medication safety
-increased patient teaching resources

List considerations when implementing the EHRS

-Office of the National Coordinator—> authorized testing and certification
-electronic infrastructure
-cost
-vocabulary standardization
-security, privacy, and confidentiality
-data integrity
-master file maintenance
-ownership of the patient record
-legal aspects related to online documentation

Review the current status of EHRSs-focus on challenges with using EHRs

-integrating behavioral health and primary care workflows
-limitations in resources
-continuous reliance on paper, including work-arounds
-difficulties with technical features
-lack of technical support for clinicians
-fragmented documentation
-a variety of usability issues

Define the strategic planning and discuss its components

-most critical issue facing decision making for information systems
-includes categorizing must-haves and nice-to-haves

Components...
-developing project plan
-risk management
-communication plans
-change-management process
-implementation
-monitoring and controlling strategies
-list of final deliverables
-final close processes with evaluations
-knowledge transfers

Identify the goals of strategic planning- focus on 'Examples of goals and rationales for the system'

-to support business and clinical decisions
-to make effective use fo emerging technologies
-to enhance the organization's image
-to promote satisfaction of market and regulatory requirements
-be cost-effective
- provide a safer environment for patients

Describe the vendor evaluation methods- focus on scoring tool

-vendor assessment questions
Ex.
-about company
-about the interface
-technical/ maintenance questions
-questions from site visits
-vendor evaluation matrix tool! (rates basic functionalities of EHR from 1-poor to 5-excellent)

List methods used to manage change when planning a new product

-behaviors are observed and should be guided through models (Kubler-Ross stages of grief, Grief model, Lewin's change model, Kotter's change management theory)
-educate staff early about needed modification
-bring staff together and explain new workflows and how these workflow will impact their day-to-day practice

Describe the team selection during planning at the project level

-based on assessment of the new system's functionality and requirements
-end users, physicians, nurses, pharmacists, IT
-consultants (support and educate team members; build functionality and specific application for the system)

Explain the advantage and disadvantage of One Vendor vs Best of Breeds

One Vendor: using one specific vendor for all desired functionality
-Advantages
—>limits interoperability issues
—>provides a standardized performance
-Disadvantages
—>lack of competition
—>organization may be locked into system due to contracts
—>may be no access to the latest and greatest technology because the one vendor can't keep up

Best of Breeds: selecting the bets technology from a number of vendors
-Advantages
—>access to the latest and greatest technology
Disadvantages
—>requires expertise of the IT team to understand
—>interoperability is an issue

Illustrate ways that implementation-committee members are selected- focus on 'form the Implementation Committee'

The implementation committee develops a project plan or timeline.

-project leader is usually a nurse leader
—> the nurse leader plans a strategy to support people and process changes as a way to promote innovation and minimize resistance
-an effective project leader lays the groundwork for the implementation committee by helping the committee identify the goals for the implementation
-at the primary level, the groundwork includes the mission, objectives, and outcomes
-at the secondary level, it includes the benefits and outcomes

Describe the importance of providing training during system implementation

Implementation:
-identify requirements for the system
-form the implementation committee
-plan the installation by developing tasks and a timeline
-create a prototype system
-conduct system tests
-prepare for Go-Live conversion

Training:
-effective training is a key element for system implementation
-training must include classrooms, instructors, computers, training scripts to teach the classes, time

Review the importance of developing work breakdown structure (WBS) during system implementation

Project planning software= Work Breakdown Structure (WBS) —> it is important and helps...
-define and schedule necessary tasks for implementation
-define the scope of each task
-describe the members' roles and responsibilities in accomplishing the tasks
-identify timelines and the "go-live" date
-identify resources and constraints

List the decisions that must be addressed when performing an analysis of hardware requirements

-network infrastructure
-review work station types and/ or mobile devices
-work station-location strategy (point-of-care devices are located at the site of client care- at bedside)
-hardware location requirements
-printer locations

Identify variables that must be considered in performing system testing process

-the testing environment is not exactly the same as the live environment because the live environment is much larger and more complex
—> the testing environment includes a copy of the software and is used to test system changes
—>system testing tests the entire system as one entity
-user acceptance testing is an independent test performed by end users prior to accepting the product

Discuss the "go-live" process and identify the method of implementation

-implementation committee determines the go-live date early in the development process
-transfer or data from old system to new system
-establishment of user and system support procedures
-development of short-term and long-term evaluation procedures
-creation of a change control procedure and a method to record changes
-method
—> rollout or Big Bang
-decisions must be made regarding what's Information will be back-loaded or pre-loaded into the system before the go-live date

Summarize several common implementation pitfalls

-inadequate understanding of how much work and resources are required to implement and maintain a system.
—> inaccurate estimates of what is required for a vendor to fully customize an information system for a specialty organization.
—> providing insufficient dedicated resources to the implementation committee.
—> failure to consider annual maintenance costs and other expenses.
—> problems with testing or training.
—> ongoing addition of changes and new features
-poor communication among the implementation committee and end users
-hostile culture or lack of system "ownership" by users

Identify the importance of communication in maintenance phase of the system's life cycle

Maintenance- period of time in which new behaviors are solidified, end users may accept or not accept new system

Communication:
-imperative for sharing information and informing users of changes
-includes electronic newsletter or printed announcement, system messages, focus groups, in-house user groups, and help desks
-help text is a 24/7 outlet for info

Explain the significance of long term system maintenance- focus on technical maintenance

-users should be able to submit requests for upgrades and changes
-ongoing maintenance must be provided in the testing, training, and production environments to support
—> problem solving and debugging
—> performing a file backup
—> maintaining a backup supply of software
—> maintaining and updating a disaster recovery plan
—> scheduling staff to perform testing
-technical maintenance is generally the responsibility of the information services department

Explain the System Development Life Cycle

-a continuous process of system development
-evaluation is critical to to the maintenance and long term acceptance of a system
1. Understand the problem and need
2. Develop an implementation plan
3. Create a prototype/ implement the system/ update the system
4. Conduct system tests
5. Get feedback during testing and evaluation from end users and other tools in the system environment
6. Perform maintenance/ develop revisions (and then go back to 3 and repeat)

Discuss privacy and confidentiality issues related to health information technology training- focus on Safeguards for privacy and confidentiality

-training environment= carefully planned replica of the HIT that will be used in actual practice
-case studies and patient scenarios that mimic the real patient-care setting are effective for teaching
HOWEVER...
-no actual patient information must be revealed during the training process!
-patient privacy and security... access a patient's HC record on a need-to-know basis, build trust relationship, protect patient info
-email-encryption for outgoing emails including pt info
-password security, length, frequent changes
-security to prevent malicious software from accessing system, USB not able to access system

Describe the rationale for training on backup procedures (downtime planning)

-education on system downtime procedures is necessary
-staff must be aware so they can continue providing safe pt care and other clinical operations without access to HIT systems
Downtime planning should include...
-forms for alternate documentation
-alternate sources of data
-communication processes
After downtime...
-data should be reentered into charts... and decide who will do the entry
-schedule for routine downtime drills
-policies and procedures
-schedule for planned downtime's that have the least impact on care
-methods for storing and accessing backup data

Identify the methods used to evaluate training- focus on Return on investment

-successful training programs incorporate formative and summative evaluation
Ex.
-reaction evaluation
-knowledge evaluation
-application evaluation
-business evaluation
-return on investment!!!
—> determining the cost and the return on investment

Explain training-delivery methods- focus on blended learning

-instructor led training
-eLearning
-self-guided learning
-just-in-time training
-blended learning
—> mixes web- or print-based instruction with classroom time
—> lower cost than classroom training

Identify the policies addressed during health information technology training

-patient privacy and security; accessing pt information on a need-to-know basis
-downtime procedure to follow
-email encryption for outgoing emails including pt information
-cleaning and care of equipment
-information uploading and downloading; how to prevent malicious software from entering software
-password security
-eliminating unauthorized photography
-portability of organizational devices (removing devices from secure areas)
-timing of screen lock, using screen guards
-boundaries and guidelines around the use of phones
-non-use of social media by staff
-system-error correction
-use of home-equipment policies around the use of home equipment

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