Nursing Informatics (CDSS)

Clinical Decision Support System

Automated tools designed to support decision-making activities and improve the decision-making process and decision outcomes similar to Artificial Intelligence (AI).

Integrated Real-Time Patient Data Base

• Combines patient data from multiple sources.

• Provide context for results interpretation.

Data Driven Mechanism

Allows event that triggers to go into effect and activate alerts and reminders automatically

Knowledge Engineer

Translate the knowledge representation scheme used in the system so clinical knowledge in the system can be extracted and translated into machine executable logic.

Time Driven Mechanism

Permit automatic execution of programs at a specific time to alert healthcare providers to carry out a specific function or ensure that action has been completed.

Long-term Clinical Data Repository

• Data collected over time from a variety of sources allowing a longitudinal patient record.

Administrative

Supporting clinical coding and documentation, authorization of procedures, and referrals

Managing Clinical Complexity and Details

Keeping patients on research and chemotherapy protocols, tracking orders, referrals follow-up, and preventive care

Cost Control

Monitoring medication orders, and avoiding duplicate or unnecessary tests

Decision Support

Supporting clinical diagnosis and treatment plan processes, and promoting the use of best practices, condition-specific guidelines, and population-based management.

Early DSS

• Internist 1

• Mycin

• CASNET

• Dxplain

Internist 1

A rule-based expert system designed at the University of Pittsburgh in 1974 for the diagnosis of complex diagnosis of complex problems in general internal medicine. Uses patient observations to deduce a list of compatible disease states

Mycin

• A rule-based expert system designed to diagnose and recommend treatment for certain blood infections.

• Extended to handle other infectious diseases.

• Represented as a set of if-then rules with certainty factors attached to diagnoses.

• A goal-directed system, using a basic backward chaining reasoning strategy.

CASNET

• Casual Associational Networks

• For Building expert systems

Dxplain

• A decision support system which uses a set of clinical findings to produce a ranked list of diagnoses which might explain the clinical manifestations.

Policy No. 1

Nursing informatics as Specialty

Policy No. 2

Nursing informatics as Practice

Policy No. 3

• Telehealth and Nursing Informatics

Health Data Standards

are agreed-upon terms which lay the foundation for clinical information systems, clinical data exchange, and system integration. They cover the methods, procedures, terminologies, specifications, and protocols for collection, storage, exchange, and retrieval of health data.

Standard Development Organizations

• Created Health Data Standards

• They define, update and maintain standards through a collaborative process that involves health IT users. SDOs are non-profit entities and receive no payment

ICD 11

Most Common Coding standard developed by WHO

for diseases and diagnosis

for mortality and morbidity statistics

SNOMED CT

• Developed and maintained by SNOMED international

• for clinical terminologies

• Application : RECORDING/PROCESSING/SHARING CLINICAL DATA

CPT

• Developed by AMA

• For medical procedures and services

• Treatment Tracking/Billing/Reimbursement

HCPS

• Developed and maintained : CMS

• Purpose : Medical Devices, products, services not covered by CPT

• Application : Billing, Medicare, Medicaid and other health plans

CDT

• Developed and maintained : ADA

• Purpose : Oral and Dental Health

• Application : Document Dental treatment

LOINC

• Developed and maintained : Regenstrief Institute

• Purpose : Lab Test and Result

• Application : Document and Share labtest and observation

NDC

• Developed and maintained : FDA

• Purpose : Pharmaceutical Products

• Application : Drug Reimbursement and Biological Products

RxNORM

• Developed and maintained : NLM

• Purpose : Clinical Drugs

• Application : Mortality and Morbidity Statistics

Syntax

structure of communication; rules in spelling and grammar.

Semantics

convey the meaning of communication; dictionary and thesaurus.

Data Exchange/Messaging Standards

• Allow transactions to flow consistently between systems or organizations because they contain instructions for format, data, elements, and structure.

HL

for administrative data such as patient demographics or encounters

DICOM

for radiology images

NCPDP

for electronic prescriptions

Terminology Standards

Provide specific codes for clinical concepts such as diseases, problem list, allergies, medications, and diagnoses that might have varying textual descriptions in a paper chart or a transcription.

Document Standards

Indicate what type of information is included in a document and where it can be found.

Most common in paper medical records is SOAP

Conceptual Standards

Allow data to be transported across systems without losing meaning and context.

Application Standard

Determine the way business rules are implemented and software systems interact.

Architecture Standards

Process involving in data storage and distribution.

Nursing Minimum Data Set

Classification system which allows for the standardized collection of essential nursing data.

The collected data are meant to provide an accurate description of the nursing process used when providing nursing care.

The minimum data elements necessary for defining the cost and quality of nursing care

American Nursing Association Steering Committee on Databases

• Support NMDS

Nomenclatures

Terms or labels for describing concepts in nursing such as diagnoses, interventions, and outcomes.

Classifications

Ordering of entities, including nomenclatures, into groups or classes on the basis of their similarities.

Taxonomy

Study of classification and simultaneously refers to the end product of classification.

NANDA (North American Nursing Diagnosis Association)

Describe a patient's reactions to the disease and to treatment.

NIC (Nursing Interventions Classification)

Standardized language for treatments that nurses perform. NIC was developed at the University of Iowa and information is published by Mosby

NOC (Nursing Outcomes Classification):

Developed at the University of Iowa. It goes beyond the work of NIC toward classification of outcomes useful in clinical nursing.

Omaha System

Developed by the Omaha Visiting Nurse Association. It covers some of the same ground as the NANDA nursing diagnoses, and incorporates the Nursing Minimum Data Set (NMDS).

Saba’s Home Healthcare

Developed at Georgetown University, focuses on community health.

UMLS Metathesaurus

NANDA, NIC, NOC, HHCC, and others

Clinical Care Classification (CCC)

Standardized, coded nursing terminology that identifies the discrete elements of nursing practice.

Perioperative Nursing Data Set (PNDS)

Describes perioperative nursing practice with a sub-set of terms that specifically describe perioperative nursing diagnoses, nursing interventions, and patient outcomes in surgical settings from pre-admission until discharge.

Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT)

Considered to be the most comprehensive, multilingual clinical healthcare terminology in the world.

Patient Care Data Set (version 4.0, 1998) (PCDS)

Contains a data dictionary and sets of terms and codes representing specific values of Patient Problems (363 terms), Patient Care Goals (311 terms), and Patient Care Orders (1357 terms). It was recognized in 1998 by the American Nurses Association (ANA) as one of the vocabularies to be considered for use by nurses, and is included in the National Library of Medicine's Metathesaurus.

Concept

Thought or reference; unit of knowledge created by a unique combination of characteristics (an abstraction of a property of an object or of a set of objects.)

Object

Referent; anything perceivable or conceivable.

Term

Symbol; verbal designation of a general concept corresponds to two or more objects which form a group by reason of common properties.

Schemata

incorporate domain-specific knowledge about the typical constellation of entities, attributes and events in the real world and reflect plausible combinations of concepts. Example: “pain” can be combined with “acute” to make “acute pain”.

Dependable Systems

Systems that are characterized by attributes such as reliability, availability, safety, confidentiality, responsiveness, survivability, integrity, and maintainability. These attributes ensure that the system behaves as expected, with minimal errors, and poses no unacceptable risks to the environment or users. It should possess all these attributes in order to be considered trustworthy. D

Clinical Information System

An information system designed specifically for use in the critical care environment, such as in an Intensive Care Unit (ICU). It can network with the many computer systems in a modern hospital, such as pathology and radiology.

care watch

home tele-monitoring program for patients with congestive heart failure

Remote Defibrilator

allows hospitals to diagnose and resuscitate a homebound patient who has suffered a cardiac arrest.

Centers for Disease Control and Prevention

mission is to monitor public health, put forth prevention initiatives, investigate health problems, and promote healthy behaviors.

Medline Plus

A consumer health resource that brings together information from various government agencies, including the National Library of Medicine, the National Institutes for Health, and others.