Data Standards
In nursing school, you likely learned about these ANA recognized terminologies and data elements. You may have been encouraged to use these to develop your nursing care plans. These three recognized standards cover nursing diagnoses, nursing interventions, and nursing outcomes.
What is NANDA / NIC / NOC ?
Patients tend to get information overload when not presented in the right format. When information is being delivered to patients, they assume this role.
Who is the information receiver?
We love our smart devices but these hardware devices alone are not enough! We also need this supplemental tool to ensure that we can use these hardware devices.
What are software applications (e.g., hardware vs. software)?
These three letters are essential to health care data exchange. This acronym represents specifications for how data can be exchanged and used across software applications.
What is an API (Application Programming Interface)?
This process verifies users upon log in to electronic systems. A nurse who logs into the system will go through this process to verify his/her credentials and identity as defined by the system.
What is authentication?
This ONC HIT recommended clinical vocabulary standard offers normalized drug names that link to commonly used vocabularies such as Micromedex and Multum.
What is Rx Norm?
The charge nurse expresses to the Informatics team how she would love to be able to see all of the rooms at a glance to know which are filled, which are open, which are pending discharge, and which need to be cleaned. The concept being represented in her request to the informatics team is not for new data but for how the data is presented.
What is data representation?
Amazon is not just for Prime membership to buy your Christmas gifts anymore. Now we can host software programs and apps on their Web Services account. The use of Amazon Web Services represents this type of computing.
What is cloud computing?
As a patient there is certain information you may be willing to share or not share with your health care team. The health care team must respect your wishes and also hold any information you share within the laws of HIPAA. These two concepts introduced are often interchanged however there are differences in their meaning.
What is confidentiality versus privacy?
This technical safeguard stores and transmits electronic PHI in a format that is unreadable to the human eye.
What is encryption?
This vocabulary standard is a requirement for electronic exchange of health information and interoperability specifications. This standard is owned and operated by the International Health Terminology Standards Development Organization (IHTSDO).
What is SNOMED CT?
Informatics is very much about effective communication. A message must be transferred from this person to the next person. For example, the person giving shift report is communicating information and representing this role.
Who is the information sender?
This has likely been the most popular word of the year that is often difficult for non-HIT'ers to pronounce. Ona serious note, this past year has shown significant advances in bringing organizations and vendors together in an effort to share data. This concept holds the hope for being able to achieve this goal over the next 10 years.
What is interoperability?
What is middleware?
Do you ever wonder why some data moves in one direction but not bi-directionally between electronic information systems? Well, specifications indicate how these specialists design these tools that will ultimately help us toward interoperability?
What are interfaces?
This standard created significant operational stress over the last several years. This standard had to be integrated into the EHR by October 1st, 2015.
What is ICD - 10?
The application of this concept in the Data, Information, Knowledge and Wisdom hierarchy is often referred to as 'intuition' in nursing practice, where you just 'know' something is about to happen to a patient. However, this 'intuition' is influenced by past experiences, patterns of behavior and expert level nursing skills.
The traditional model of hosting electronic health record systems and other clinical applications is known as this. There are data centers to house the back ups in case of a failure to ensure the security of the electronic PHI.
What is a client-server based architecture?
This international standards organization has provided protocols for data exchange for decades. Most recently, this organization has formed a more nimble and flexible interoperability standard that is being tested by leading vendors and organizations.
What is HL-7 and FHIR?
This security measure is a requirement of health care organizations in order to protect the electronic PHI's integrity. This can be in either a hardware or software format and is used to prevent harmful or inappropriate data from entering or leaving a network.
What is a firewall?
Virginia Saba is well known as a pioneer in Nursing Informatics. What is not as well known is the ANA recognized terminology that she developed that also has discrete data elements for diagnoses, interventions, and outcomes.
What is the Clinical Care Classification (CCC) System?
The use of electronic records of patient data has made secondary data analyses easier. The data exists in an excel format and this minimizes the need for data entry. With such data, insights about health outcomes can be determined with the appropriate methods and tools. Yet, to do so requires a step by trained researchers and statisticians. This step is called...
What is data mining?
A vendor approaches a health care organization with the desire to incorporate apple watches into a physician practice. The informatics nurse asks several questions about infection control, screen visibility, and data integration. These are just a few of the questions essential to appropriately conduct this type of evaluation.
What is a needs assessment?
This method of data storage is preferred over its alternative acronym. This method of data storage only allows for reading of the data storage. However, using this method, the data is not easily altered or reprogrammed. The alternative is more volatile.
What is Read Only Memory (e.g., RAM vs. ROM)?
Various consumer goods stores (such as Walmart) use this technology for inventory. Some health care organizations have adopted this technology to track devices. Future uses of this technology are anticipated.
What is RFID (Radio Frequency Identification)?