1. Aims of the National Quality Strategy (NQS):
    –Better care

    –Affordable care

    –Healthy populations and communities
  2. Role of HIT with the Patient Protection and Affordable Care Act (PPACA):
    –Ensures transparency

    –Increases efficiency

    –Engages consumers

    –Provides data to effectively manage care cost and quality
  3. –Two sets of regulatory requirements to meet the meaningful use (MU) of electronic health records (EHRs)
    Standard one defines the MU of EHRs

    Standard two specifies how EHRs are developed and certified to meet MU criteria
  4. –implemented an EHR incentive program to encourage providers and hospitals to adopt and implement certified technology
    Centers for Medicare & Medicaid Services (CMS):
  5. ACA Established metrics to measure success, improve quality, and create efficiency
    Five performance domains:
    –Patient/caregiver experience

    –Care coordination

    –Patient safety

    –Preventive health

    –At-risk population/frail elderly health
  6. Three phases of meaningful use (MU)
    Phase 1
    –Implement a certified EHRs meeting basic requirements
  7. Three phases of meaningful use (MU) Phase 2
    –Consumer engagement and increases the capture and exchange of data
  8. Three phases of meaningful use (MU) Phase 3
    Capture and exchange more structured data, support population health management, measure outcomes, and maintain patient-centered care
  9. Programs reward health care providers for adopting, implementing, and meaningfully utilizing a certified EHR
    EHR Incentive Program
  10. Nurse practitioners are used within which incentives program
  11. EHR vendors must develop products
    according to specific criteria in order to be certified
  12. EHR Incentive Program: Providers must adhere to
    specific criteria to meet meaningful use
  13. EHR Incentives program: Penalties will occur for providers who
    fail to adopt EHRs or fail to meet meaningful use
  14. Cornerstone of meaningful use is
    patient engagement
  15. Components for reformation of health care delivery:
    –Technology for lowering cost and improving safety

    –Assurance of patient safety and quality in a technology-driven environment

    –Nursing’s diverse role as HIT advances
  16. Patient Safety and Quality in Technology-Driven Environments: Rapid deployment of technology in health care environment can
    inadvertently cause patient harm
  17. what should be used as a guide to implement safe HIT systems for better care
    The Department of Health and Human Service’s book
  18. Informatics nurses should be involved in
    development of EHR products and integration of the EHR with the flow of direct patient care
  19. who will be involved with primary care to patients gained from the expansion of affordable health care
    Advanced practice nurses
  20. Nursing Education for Healthcare Informatics Model framework is targeting advanced practice care delivery is composed of what 3 main content domains
    –Point-of-care technology

    –Data management and analytics

    –Patient safety/quality and population health
  21. Relates to the first content domain (NEHI)
    Reflects applied information management tools to transform data and information into improved health care delivery
    Data Management and Analytics
  22. Relates to the second content domain of the NEHI framework
    Reflects quality improvement tools applied to individuals, as well as to public health initiatives
    Patient Safety/Quality and Population Health
  23. Organized according to the NEHI framework
    Includes a final section on new and emerging technologies
    Text Organization
  24. new “buzzword”
    Interprofessional team:
  25. Health care and social assistance employment positions are INC or DEC in US
  26. Work involves the identification, definition, management, and communication of data, information, knowledge, and wisdom
    Informatics Nurse Specialist
  27. Support colleagues, health care consumers, patients, the interprofessional health care team, and other stakeholders
    Serves as the translator between clinical and information technology personnel and sectors
    Serve as translators and liaisons for health care consumers and patients
    Informatics Nurse Specialist
  28. ANA Identified NI as a nursing specialty in
  29. ANA Published the specialty’s first scope of practice statement in
  30. ANA Published NI standards of practice in
  31. –The last publication, Nursing: Scope and Standards of Practice, Second Edition includes:
    Competencies describing the integration of knowledge, skills, abilities, and judgment
    –American Association of Colleges of Nursing (AACN)

    –National League for Nursing (NLN)

    –Quality and Safety Education for Nurses (QSEN) project

    –Technology Informatics Guiding Education Reform (TIGER) initiative

    –Nursing Education for Healthcare Informatics (NEHI) model
  33. Initiatives that support interprofessional teamwork in healthcare include:
    –Interprofessional Education Collaborative (IPEC®)

    –World Health Organization (WHO)

    –Institute of Medicine (IOM)

  34. –Limits the impact of interprofessional teams by language that focuses on physician reimbursement through the Medicare/Medicaid incentive structure
    Meaningful use and the HITECH Act:
  35. Stages of theory development:
    –serve phenomenon

    –Explain the phenomenon

    –Model developed

    –Model tested and refined

    –Used to test propositions within the theory

    –Aid in the building of enlightenment

    –Used to narratively describe complex processes
    Middle range/Mid-Range:
  37. –Appreciates the importance of humans and technology

    –All things have the potential to interact and generate action
    Socio-technical systems
  38. New HIT changes the
    –present social system
  39. Various existing infrastructures mediate
  40. Preexisting social systems facilitate
    –reinterpretation of HIT-in-Use
  41. HIT-in-Use influences and changes
    –pre-established social systems
  42. HIT-in-Use and social system interactions affect
    overall HIT redesign
  43. No single definition or value accepted
    Considered a dynamic non-static construct
    Can be approaches or tools
  44. Quality Improvement  Approaches:
    –Plan-Do-Study-Act (PDSA) model

    –Donabedian approach: structure, process, outcome
  45. Socio-Technical Perspectives
    • Activity theory
    • Complexity theory
    • Socio-technical Systems Theory
    • Actor-Network Theory (ANT):
  46. –The primary socio-technical approach for QI activities

    –All things in an environment are individual actors

    –Actors are dynamic entities able to change the context around them
    Actor-Network Theory (ANT):
  47. –Human or non-human entities that perform action
  48. –Group of actors
  49. –Process of stimulating action
  50. –Stabilized action network
    Black Box network:
  51. Can be self-limiting
    Realize humans and technology are different with corresponding different responses
    Focus is on how actors interact with each other and the environment
    Use of ANT
  52. EHR penetration rate has increased since 2010 with the implementation of the
    HITECH Act
  53. HIT adoption for adoption’s sake was never
    the goal
  54. HITECH Act included funding for six major initiatives:
    –EHR Incentive Program

    –EHR Certification Program

    –State HIE Program

    –Regional Extension Center (REC) Program

    –Beacon Community Program

    • –Workforce Development:
    • Community College Curriculum
    • University Based Training

    –Strategic Health IT Advanced Research Projects (SHARP)
  55. Meaningful use: defined by the
    EHR incentive program
  56. Office of the National Coordinator for Health Information Technology (ONC): ran out of
    funds for the programs
  57. EHR Incentive Program: the framework for
    promoting EHR adoption
  58. Creation of Health Information Exchanges (HIE)
    Three designs:
    –Central data repository model

    –Federated model using local repositories

    –Hybrid model with elements of both types
  59. Changes occurred 2011 where EHRs to become certified must be capable of
    Nationwide Health Information Network Direct (NwHIN Direct) or Direct
  60. Designed to demonstrate clinical quality improvements possible in communities with more robust EHR adoption
    Beacon Programs
  61. BEACON PROGRAMS Three part aim of the communities:
    –Improve population health

    –Test innovative approaches

    –Build health IT infrastructure
  62. Knowledge gained from the Beacon programs help design
    learning guides
  63. BEACON Guides provide information about
    community challenges with HIT implementation and how to overcome obstacles
  64. RECS  Direct funding tied to specific operational milestones:
    –Enrollment with the REC

    –Go-live on an EHR

    –Provider achieved Meaningful Use
  65. Awarded to Universities or research institutions
    Designed to support research to address critical areas of EHR functionality:
    Research and Technology Development SHARP Grants
  66. Sharp S:
    –Privacy and security
  67. Sharp C:
    –Physician cognition and decision-making
  68. Sharp A:
    –Health application design
  69. Sharp n:
    –Use of EHR data
  70. Grant awarded to support medical devices
    MD Sharp:
  71. Four grants for workforce development:
    –Community colleges

    –University-based training program

    –Northern Virginia Community College to develop a Competency Exam
  72. Each program designed to compensate for different challenges which could derail or slow broad adoption efforts
    Interlocking Programs
  73. The three most critical programs: INTERLOCKING
    –EHR incentive program

    –REC program

    –State HIE program
  74. Shared decision making: process of integrating patients’ goals and concerns with medical evidence to achieve high-quality medical decisions
    Patient Engagement
  75. Providing patients with evidence: (PATIENT ENGAGEMENT)
    –Impacts choices

    –Better understanding of treatment options

    –Better understanding of screening recommendations

    –Higher satisfaction

    –Choices resulting in lower cost

    –Better health outcomes
  76. Patient engagement a part of Stage 2 of the
    HITECH Act
  77. National Quality Strategy and National Prevention Strategy support
    patient involvement in health care
  78. Approaches to empower people:
    –Provide with tools and information to make healthy choices

    –Promote positive social interactions and support healthy decision making

    –Engage and empower people and communities to plan and implement prevention policies and programs.

    –Improve education and employment opportunities
  79. Approaches to empower people in health care:
    –Confirm understanding of health promotion and disease prevention

    –Involve consumers in planning, developing, implementing, disseminating, and evaluating health and safety information

    –Use alternative communication methods and tools to support more traditional written and oral communication.

    –Refer to adult education and English-language instruction programs enhance understanding of health promotion and disease prevention messages
  80. Patient Engagement Approaches
    • Patient Engagement in Health and Health Care Framework
    • Health Information Management Systems Society (HIMSS) Model
    • Ensure basic needs are met
    • Address health literacy
    • DNA analyses
    • Web sites to share health information
  81. Provider Approaches/ Models/Competencies (APPROACHES)
    –Interprofessional education/collaborative

    –Support patient activation
  82. Provider Approaches/ Models/Competencies (MODELS)
    –Family Health Model

    –Betty Neuman Model of health

    –Family systems theory (FST)

    –Patient- and family-centered care
  83. Provider Approaches/ Models/Competencies (COMPETENCIES)
    –Dietetics Workforce Demand Study
  84. Create a learning health care system with the characteristics of: 4 THINGS
  85. Create a learning health care system with the characteristics of:

    –Science and informatics:
    • Real-time access to knowledge
    • Digital capture of the care experience
  86. Create a learning health care system with the characteristics of: Incentives
    • Incentives aligned for value
    • Full transparency
  87. Create a learning health care system with the characteristics of: Culture
    • Leadership-instilled culture of learning
    • Supportive system competencies
  88. computing power will double every 2 years
    Moore’s Law
  89. standard unit of measure in computers
  90. basic whole unit of information used to form the written codes assigned to retrievable computer data archives known as “the memory”
  91. –Motherboard, CPU, RAM, power supply, video card, HDD, SSD, optical drive and card reader
  92. –The field of study focused on understanding human elements of systems, where systems may be defined as software, medical devices, computer technology, and organizations
    Human factors
  93. processing speeds, memory requirements, interface equipment, operating system requirements, and software to run the clinical software
  94. Programming language classifications:
    5 generations
  95. system, application, programming tools
  96. EHR Software Selection
    • Specific to an organization
    • Cost and quality decision
    • Based on the needs of the organization and the end users
    • Selected after completing the 12 essential steps prior to the purchase of an EHR
  97. company provides software on a server that can be accessed from the Internet
    Cloud computing
  98. Some elements of documentation computerized as far back as the
  99. De-Centralized Hospital Computer Program used in the Department of Veteran Affairs in the
  100. is the standard the exchange, integration, sharing, and retrieval of health information
    Health Level Seven International (HL7)
  101. Lab and patient registration were computerized WHEN?
  102. Impact of EHRs:
    –Improve quality of patient care

    –Increase patient participation in their care

    –Improve accuracy of diagnoses and health outcomes

    –Improve care coordination

    –Increase efficiencies and provide cost savings
  103. Automatically checks for problems with new medication prescriptions and alerts to potential conflicts
    Coordinates care
    Reduce operation costs
    Cost avoidance of care related to delays in care or medical errors
    Features of EHRs Supporting Quality and Safety
  104. Three ways to make an EHR decision:


    –Combination of both
  105. provide a common language and set of expectations enabling interoperability between systems and/or devices
  106. Steps Before Implementation OF EHR
    • Request for proposal (RFP)
    • Live or virtual demos of the system
    • Site visits to see the system in use in other organizations
    • Budgetary review
  107. System Development Life Cycle (SDLC) approach PHASES




    –Support and maintenance
  108. Workflow Analysis
    –Staff using workflows should be involved in workflow development

    –Increases standardization and reinforces policies and procedures to follow the new workflows

    –Decreases variability while increasing efficiencies
  109. “Use” cases
    Follows Actor-Network-Theory
    “Use” cases created for every workflow
    Build Process
  110. Informatics nurse’s role:
    –Understands clinical aspects of the effects of the EHR on clinicians and patients

    –Assesses and monitors the impact on patient care and clinician’s experience

    –Understands workflows and system functionality

    –Positioned to solve problems, establish best-practices, and adapt policies and procedures to support workflows
  111. Superusers role:
    –First-line resources

    –Pivotal, point-person during the go-live
  112. How well the EHR is used and embraced as part of routine activities
  113. Levels of adoption:

    –Early adopters

    –Early and late majority

  114. Evaluation
    • Surveys
    • Questionnaires
    • Focus groups
    • Ethnographic observational methods
    • Staff interviews
    • Workflow analysis pre and post
  115. Point-of-Care
    • Medication administration: Barcode
    • Diagnostic testing: Glucose
    • Issue surrounding FDA approval because of direct use with patients
  116. Ability to pull in data from source systems and integrate the data from the devices into the EHR
    Can be expensive
  117. Issues with legacy systems


    –Ease of use


    –Return on investment
  118. Challenges With Integration
    • Wi Fi access unstable or non-existent
    • Data reliability and validity
    • Addressing rules and alerts
    • Over-reliance on technology
    • Associating devices with patients
    • Acting on results
  119. Change management:
    –Maintenance requests

    –Regulatory changes

    –Patient safety changes

    –User requests
  120. SDLC  Is a process
    (Must align the needs of the user with the deliverable)
    Primary goal IS?
    Meet or exceed customer expectations
  121. SDLC Phases:



    –Implementation and testing

    –Evaluation, maintenance and support
  122. SDLC Most important tool IN PLANNING
    customer site visit
  123. SDLC PLANNING Outputs from this phase:
    –Product concept document

    –Feasibility assessment

    –Product scope document
  124. Role of the informatics nurse: SDLC PLANNING
    create a project charter
  125. Parts of the charter:
    –Project Champion


    –Problem or Opportunity Statement


    –Key stakeholders


    –Target Benefits

  126. SDLC ANAYLSIS Key objectives:
    –Outline end-user requirements

    –Data flows, processes and workflows

    –Outline detailed system specifications

    –Conduct market analysis
  127. “tools of the trade” for the analysis
    Data flow diagrams:
  128. Outputs from this phase (SDLC ANALYSIS)
    –Report to stakeholders


    –End-user requirements
  129. Design strategies:
    –Waterfall method

    –Rapid application development (RAD)

    –Agile techniques

  130. Implementation, Evaluation, and Support Phase
    Focus on:
    –End-user acceptance

    –System performance

    –Ongoing maintenance and support plan
  131. Implementation, Evaluation, and Support Phase Tools
    –Strategy plans for go-live

    –Data plans for conversion of old data into the system

    –Command center

    –User-support center
  132. Go-live phase
    Implementation, Evaluation, and Support Phase
  133. Implementation, Evaluation, and Support Phase
    Pilot testing approaches:
    –Phased or incremental

    –Big bang

    –Parallel systems
  134. System Evaluation METRICS
    –System stability

    –Strategic plan adherence

    –Cost avoidance

    –Risk reduction

    –Long-range goals

    –Improvements in quality, safety, and population health improvements
  135. Types of workflow diagrams:
    –Simple linear

    –Swim lane or cross functional

    –Spaghetti diagram

    –Value Stream Map

  136. Used to:

    –Identify areas of concern

    –Opportunities to improve a process
    workflow diagrams:
  137. Steps to Workflow Redesign
    • Identify process to be mapped
    • Identify and involve individuals who perform the tasks
    • Map the current state
    • Assess current state workflow
    • Identify opportunities for improvement
    • Identify data to measure redesign outcomes
    • Map future “to be” process
    • Test new workflows and processes
    • Train on new workflows and processes
    • Go live with the new workflows and processes
    • Analyze data and refine workflows and processes
  138. End-user satisfaction:
    –Focus groups

  139. Return on investment (ROI):
    –Technical expenses for software, hardware, networking

    –Man hour costs of labor for technical, clinical, and clinician time and effort
  140. Consider rip and replace:
    –Vendor goes out of business

    –New vendor has a superior product

    –A serious problem with the EHR that fails to accommodate new technologies

    –Business model shifts and changes traumatically
  141. Promotes EHR-enabled improvement in patient outcomes through sharing case studies and lessons learned on implementation strategies, workflow design, best practice adherence, and patient engagement.
    –“The Davies award”:
  142. Measures of Success
    • USEFUL
    • Feasible
    • Ethical
    • Accurate
  143. –A fundamental concept under the HITECH Act and

    –Vital for establishing meaningful use (MU)
    Exchange of health information:
  144. Models for HIE
    –Data sharing protected through data sharing agreements

    –Data are stored for use by organizations through data repositories
  145. Models for HIE Decentralized
    –Federated model

    –Maintains control of the source data at the originating organization
  146. Models for HIE
    Technical exchange:
    –Direct messaging

    –Query-based transactions
  147. –Identify unique patients within a delivery system maintaining disparate information systems or across institutions within regions
    MPI purpose:
  148. –Method of creating a single record from two or more records that belong to the same person
    Record linkage
  149. Value of HIE With EHR
    • Fewer repeat procedures
    • Reduced medication errors
    • Specific results from studies
  150. NwHIN standards: Three areas:
    • Content structure specifications
    • Transport and security specifications
    • Vocabulary and code set specifications
  151. PHIN standards:
    –Cascading alert checklist
  152. Standards Development
    Four basic methods:
    –Ad hoc

    –De facto


  153. Standards Development Groups

  154. Common Data Standards
    • Functional Specifications of EHRs
    • Messaging
    • Clinical documentation standards
    • Medical imaging and communication
    • Code sets, vocabularies and values
    • ICD and CPT code Sets
  155. Gaps in Standards
    • Data quality
    • Advanced directives
  156. Process of linking interoperable components from one system to another
    Involves mapping “one component to another”
    An essential component for interoperability
    Positive and negative consequences
    Data Mapping
  157. Types of map relationships:
    –One to one

    –One to many

    –No match
  158. Data Mapping  determined by the distribution of the map relationships for a given map
  159. Desired Characteristics for Controlled Medical Vocabularies
    • Content
    • Concept orientation
    • Concept permanence
    • Non-semantic concept identifier
    • Polyhierarchy
    • Formal definitions
    • Rejection of not elsewhere classified
    • Recognized redundancy
    • Multiple granularities
    • Multiple consistent viewsGraceful evolution
  160. Evidence-based analysis of the health-related strengths, weaknesses, opportunities, and threats for a specified community
    Community Health Assessment
  161. Community Health Assessment Take into account input from
    persons who represent the broad interests of the community served by the hospital facility
  162. Community Health Assessment
    CDC Voluntary Accreditation Program:Core functions
    • Assessment
    • Policy development
    • Assurance
  163. Most effective assessments are grounded in
    collective impact
  164. Function as a tool to rebuild communities
    Assessment Process
  165. Assessment Process
    Data analytic strategies:
    –Compile secondary data

    –Inpatient utilization patterns

    –Primary data collection

    –New data sources
  166. Assessment Process
    –Population density


    –Birth and birth-related information

    –Mortality and morbidity

    -Access to primary care
  167. Assessment Process
    • Analyze the data
    • Triangulate the data
    • Set priorities: Focuses on areas of most concern to the residents
  168. Intervention and Evaluation Monitoring progress for actions step done how often
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