Feb 23, 2024 Discussion: Standardized Terminology and Language in Informatics
Discussion: Standardized Terminology and Language in Informatics
This week I would like to discuss the importance of usability as it relates to healthcare informatics. Usability is defined as “the ability for a product such as software system or web-based applications to be used in the healthcare setting” (Hebda, 2019). Within usability for nursing, software should be user friendly. This should mean that the applications are easy to be used by the user, with minimal errors, to be highly efficient and effective. An increased usability of an EHR is linked with decreased patient safety events, decreased employee burnout and errors, and a higher acceptance of the use or EHR in the workplace (Boldt, 2020.) Not only does usability affect patient safety, it also plays a huge role in productivity. An efficient EHR can help the user to complete tasks faster and more efficiently, therefore increasing user productivity overall. Usability of the EHR in nursing has an extremely important role in the workplace, and can ultimately either be to its detriment or benefit.
In my own nursing practice, I have found the usability of my EHR to be great. I am sure there is always a way to make things run more smoothly, but as a new nurse I have trouble seeing flaws in my current EHR as of yet. This fall my facility is going to begin the process of switching from my current EHR Soarian to Epic due to a recent acquisition so that all of the hospitals can function on the same EHR. I have heard great things about the usability of Epic. While hesitant to embrace a new way of working, I am ready and open to try software that will have better overall usability.
Discussion: Standardized Terminology and Language in Informatics
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Interoperability is the focus I am using for the discussion this week. Interoperability is in short, the exchange of information to others with the use of information systems. “Health data exchange architectures, application interfaces and standards enable data to be accessed and shared appropriately and securely across the complete spectrum of care, within all applicable settings and with relevant stakeholders, including by the individual.” (himss.org 2020). We all have probably experienced interoperability of systems within a small-scale exchange between local hospitals and physicians’ offices. We know that with HIPAA and other factors including costs, the integration of a massive scale of information exchange is going to take time. There is also the need for public input. Some individuals may have an issue with a national system for medical health records. “Any future standards and implementation specifications will include future public comments and HITSC recommendations for 2017 and future years.” (Hebda, Hunter & Czar. 2019). Interoperability of healthcare systems to share information for not only basic health information, but for most healthcare information has the potential to go global and I think it will sometime in the future.
I am currently a Case Manger for a health insurance company. The company I work for has several systems that we can retrieve information. One of our systems is the RX Claims system and that allows us to see in real time a patients current medications. We can see the dates, times, dosages, quantity filled and who prescribed the medication. This helps when patients are unable to recall medications. This system also allows us to see a trend with possible over utilization of prescriptions or patients are filling their medications on time and allows us to note they may not be taking as prescribed which can lead to exacerbation of health issues. We have a state wide system with OARRs that allows us to see if patients are “doctor shopping”. Some patients will pay cash for some medications and this does not go into our RX Claims system, but we can see through the OARRS system if the patient is filling prescriptions outside of the insurance. It also has the physician enter every patients name with the medication prescribed. I would like to see a nationwide database similar to the OARRS system so that when we see a potential issue with substance abuse, we could possibly intervene sooner and save not only cost on the many medical issue that occur because of substance abuse, but to get the patient help for the purpose of being compassionate and caring, knowing the potential effects this can have on an entire family.
The future of interoperability could have a huge impact on my current position. I spend a lot of time contacting physicians asking for information about a patients last visit or any new issues for the patient. I contact hospitals and nursing homes to check on patients to get up to date information. With interoperability, I could possibly go into a system and see how the patient is, the last patient notes and treatment plan. This could help me better understand how to transition the patient back to home with less time contacting doctors, hospitals and nursing homes and waiting for call backs and possibly missing information through the conversation.
Hebda, T., Hunter, K. & Czar, P. (2019). Handbook of informatics for nurses and healthcare professionals (6th ed.). Pearson.
Interoperability in the Healthcare Ecosystem. (2020). Retrieved from: https://www.himss.org/what-interoperability#:~:text=Interoperability%20is%20the%20ability%20of,seamless%20portability%20of%20information%20andLinks to an external site.
I work with adults, so Medicare is a common thing the unit has to deal with. While I don’t really interact with Medicare directly, I know what I do and what I document can affect what is reimbursed to the hospital. Preventable things like falls or hospital-acquired pressure injuries and infections should never happen and negatively affect what Medicare pays. When a patient is admitted, it is our policy that two nurses look over the patient’s skin to find any pressure injuries or any other skin issues. If any pressure injuries are missed, it will impact our payment. Even if we know they had it when they came in, if it wasn’t documented within 24 hours of them arriving it is technically our fault. This strict documentation is important in all areas of healthcare, including skilled nursing facilities and long-term care facilities. One could argue that a SNF might be look at more closely considering the amount of time the patient will spend there.
The nurse at the SNF is required to do an initial assessment to see if the patient will qualify for their services and if Medicare will pay for those services. The nurse also documents diagnoses, conditions, functional limits, treatments, and any medications given. Everything that is documented is them subject to review by the billing department. Any documentation deficits will negatively affect the payment, therefore costing the SNF to lose money on services already provided (Micheletti, Shlala, & Greenfield).
Medicare will pay for what they believe is necessary and often times the rest falls onto the facility or hospital to pay. That’s why documenting everything that is required to make Medicare happy is so important.
Micheletti, J. A., Shlala, T. J., & Greenfield, C. E. (n.d.). Optimizing Medicare reimbursement in skilled nursing facilities. Healthcare Financial Management, 38-42.
Question Description
I’m trying to study for my Health & Medical course and I need some help to understand this question.
Please see reading assignment, actual requirements with attached articles for assignment. Due date will be Wednesday, September 19th, 2018 @ 9am.
Standardized Terminology and Language in Informatics
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Standardized Terminology and Language in Informatics
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patient_education_technology_guide_to_a_mobile_health_application_powerpoint.ppt
patient_education_technolgy_guide_to_a_mobile_health_application___outline.doc
himss_interoperability_definition_final.pdf
evidence_20for_2
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
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