Standardized Coding Systems

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Standardized Coding Systems

As a result of the fragmented nature of the health care system, professionals in various specialty areas of medicine have developed their own unique sets of terminology to communicate within that specialty. In the past, limited attention has been given to codifying practices in order for them to be understood and utilized across disciplines or through different information technology systems. The implementation of a federally mandated electronic medical records system, therefore, poses a challenge to nursing professionals and others who must be prepared to utilize standardized codes for the new system. Why are coding standards important for promoting consistent, high-quality care?

According to Rutherford (2008, para. 15), “Improved communication with other nurses, health care professionals, and administrators of the institution in which nurses work is a key benefit of using a standardized nursing language.” In this Discussion you consider the reasoning behind and the value of standardized codification.

To prepare:

  • Review the information in Nursing Informatics: Scope and Standards of Practice. Determine which set of terminologies are appropriate for your specialty or area of expertise.
  • Reflect on the importance of continuity in terminology and coding systems.
  • In the article, “Standardized Nursing Language: What Does It Mean for Nursing Practice?” the author recounts a visit to a local hospital to view its implementation of a new coding system. One of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1). Consider how you would inform this nurse (and others like her) of the importance of standardized nursing terminologies.
  • Reflect on the value of using a standard language in nursing practice. Consider if standardization can be limited to a specialty area or if one standard language is needed across all nursing practice. Then, identify examples of standardization in your own specialty or area of expertise. Conduct additional research using the Walden Library that supports your thoughts on standardization of nursing terminology.

Post on or before Day 3 an explanation of why nurses need to document care using standardized nursing languages and whether this standardization can be limited to specialty areas or if it should be across all nursing practice. Support your response using specific examples from your own specialty or area of expertise and using at least one additional resource from the Walden Library

Readings

  • American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.).Silver Springs, MD: Author.
    • “Metastructures, Concepts, and Tools of Nursing Informatics”

      This chpater explores the connections between data, information, knowledge, and wisdom and how they work together in nursing informatics. It also covers the influence that concepts and tools have on the field of nursing.

  • McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
    • Chapter 6, “Overview of Nursing Informatics”

      This chapter defines the foundations of nursing informatics (NI). The authors specify the disciplines that are integrated to form nursing informatics, along with major NI concepts.

    • Chapter 7, “Developing Standardized Terminologies to Support Nursing Practice”

      This chapter explores the need for consistent nursing terminology. The authors also detail the different approaches to developing terminology.

  • Brokel, J. (2010). Moving forward with NANDA-I nursing diagnoses with Health Information Technology for Economic and Clinical Health (HITECH) Act Legislation: News updates. International Journal of Nursing Terminologies & Classifications, 21(4), 182–185.
    Retrieved from the Walden Library databases.

    In this news brief, the author describes the initiatives that NANDA-I will implement to remain abreast of the HITECH legislation of 2009. The author explains two recommendations for the federal government’s role in managing vocabularies, value sets, and code sets throughout the health care system.

  • Matney, S., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework. Advances in Nursing Science, 34(1), 6–18.
    Retrieved from the Walden Library databases.

    This article proposes a philosophical foundation for nursing informatics in which data, information, and knowledge can be synthesized by computer systems to support wisdom development. The authors describe how wisdom can add value to nursing informatics and to the nursing profession as a whole.

  • Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing, 13(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.html

    The author of this article provides justification for the use of a standardized nursing language, which will be necessary for incorporating electronic documentation into the health care field. The author defines standardized language in nursing, describes how such a language can be applied in a practice setting, and discusses the benefits of using a standardized language.

  • Westra, B. L., Subramanian, A., Hart, C. M., Matney, S. A., Wilson, P. S., Huff, S. M., … Delaney, C. W. (2010). Achieving “meaningful use” of electronic health records through the integration of the Nursing Management Minimum Data Set. The Journal of Nursing Administration, 40(7–8), 336–343.
    Retrieved from the Walden Library databases.

    This article explains the nursing management minimum data set (NMMDS), which is a research-based minimum set of standard data for nursing management and administration. The article describes how the NMMDS can be used to minimize the burden on health care administrators and increase the value of electronic health records within the health care system.

Media

  • Laureate Education, Inc. (Executive Producer). (2012a). Data, information, knowledge, and wisdom continuum. Baltimore, MD: Author.
    McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning. (p. 98, Chapter 6, Figure 6)

    The continuum of data, information, knowledge, and wisdom is used in the health care field to describe discrete levels of understanding related to patient care and decision making. This video provides an overview of the continuum from data to wisdom.

Optional Resources

  • Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal, 39(2), 37–39.
    Retrieved from the Walden Library databases.
  • Brown, B. (2011). ICD-10-CM: What is it, and why are we switching? Journal of Health Care Compliance, 13(3), 51–79.
    Retrieved from the Walden Library databases.

PPACA

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The PPACA of 2010

PPACA of 2010 brought many changes to the types of provider organizations available. ACOs and PCMHs are two new organizations formed under PPACA. Using the readings this week, discuss the origin, structure, and purpose of the new organizations formed under PPACA.

Using South University Online Library (for example, CINAHL) or the Internet, search any three articles from the list below and evaluate the challenges and opportunities facing payers and providers as ACOs and PCMHs are implemented:

  • The patient-center medical home and managed care: Times have changed, some components have not (Baird, 2011).
  • Patient-centered medical homes: Will health care reform provide new options for rural communities and providers? (Bolin, Gamm, Vest, Edwardson, & Miller, 2011)
  • Accountable Care Organizations: The case for flexible partnerships between health plans and providers (Goldsmith, 2011).
  • Payment reform for primary care within the accountable care organization a critical issue for health system reform (Goroll & Schoenbaum, 2012).
  • Accountable care organizations, the patient-centered medical home, and health care reform: What does it all mean? (Longworth, 2011)
  • Implementing accountable care organizations: Ten potential mistakes and how to learn from them (Singer & Shortell, 2011).

Based on your research, summarize your findings on the selected topics and compile your observations in a 5- to 6-page Microsoft Word document.

Support your responses with examples.

Cite any sources in APA format.

 

References:

Baird, M. A. (2011). The patient-center medical home and managed care: Times
have changed, some components have not. The Journal of the American
Board of Family Medicine, 24(6), 630–632.

Bolin, J. N., Gamm, L., Vest, J. R., Edwardson, N., & Miller, T. R. (2011).
Patient-centered medical homes: Will health care reform provide new
options for rural communities and providers? Family & Community
Health, 34(2), 93–101.

Goldsmith, J. (2011). Accountable Care Organizations: The case for flexible
partnerships between health plans and providers. Health Affairs,
30(1), 32–40.

Goroll, A. H., & Schoenbaum, S. C. (2012). Payment reform for primary care
within the accountable care organization a critical issue for health system
reform. JAMA: The Journal of the American Medical Association,
308(6), 577–578.

Longworth, D. L. (2011). Accountable care organizations, the patient-centered
medical home, and health care reform: What does it all mean?
Cleveland Clinic Journal of Medicine, 78(9), 571–582.

Singer, S., & Shortell, S. M. (2011). Implementing accountable care
organizations: Ten potential mistakes and how to learn from them. JAMA:
The Journal of the American Medical Association, 306(7), 758.

 

Assignment 2 Grading Criteria
Maximum Points
Discussed the impact of health care reform on patients and providers.
5
Evaluated the impact of patient-centered medical homes on the delivery of health care.
10
Evaluated the impact of ACOs on the delivery of health care.
10
Discussed the challenges facing patients and providers as ACOs and PCMHs are formed.
10
Discussed the opportunities facing patients and providers as ACOs and PCMHs are formed.
10
Used correct spelling, grammar, and professional vocabulary. Cited all sources using APA format.
5
Total:
50

 

 

 

******** SECOND******                        **********second***************

Alcohol and Related Conditions

This week’s readings have covered various topics in historical perspectives. As addiction professionals, it is going to be important for you to stay current in the research and best practices of this industry. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is the first survey that uses the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) definitions of independent mood and anxiety disorders to examine comorbidity or co-occurrence of mental health disorders. The NESARC results show that substantial comorbidity between substance use disorders and independent mood and anxiety disorders is pervasive in the general population of the United States.

An estimated 17.6 million American adults (8.5 percent) meet the standard diagnostic criteria for an alcohol use disorder and approximately 4.2 million (2 percent) meet the criteria for a drug use disorder (Grant & Dawson, 2006).

“This study does not resolve questions about causal mechanisms that may underlie relationships between DSM-IV substance use and mood and anxiety disorders,” opines Bridget F. Grant, Ph.D., Chief of the Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research. Analyses of data from NESARC’s “second wave” in 2004–2005 will help form the foundation for future etiologic research (Grant & Dawson, 2006).

Using the South University Online Library or the Internet, research further on information by NESARC on alcohol and related conditions. Based on your research and the above information, create a 4- to 5-page Microsoft Word document that includes the answers to the following questions:

  • According to the NESARC, how prevalent are mood, anxiety, and personality disorders among alcohol- and drug-dependent persons?                 
  • Compared to nondependent persons, how likely is it for nicotine-alcohol-dependent persons to havea mental disorder?
  • What other disorders might you see coexisting together? Why? How are these disorders related?
  • Why is it that people with dual disorders are at high risk for chronic relapse, emergency hospitalizations, vocational problems, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, and early death?
  • Do you agree with National Institutes of Health’s (NIH’s) observation that the adults with nicotine dependence or psychiatric disorders consume 70% of all cigarettes smoked in the United States? Why or why not?

Support your responses with examples.

Cite any sources in APA format.

Reference:

Grant, B. F., & Dawson, D. A. (2006). Introduction to the national epidemiologic
survey on alcohol and related conditions. Alcohol Research & Health,
29 (2), 74–78.

Assignment 2 Grading Criteria
Maximum Points
Explained the prevalence of mood, anxiety, and personality disorders among alcohol- and drug-dependent persons.
10
Described how likely is it for nicotine-alcohol-dependent persons to have a mental disorder as compared to nondependent persons.
10
Explained the other disorders that might coexist together. Described how these disorders are related.
10
Described why people with dual disorders are at high risk for chronic relapse, emergency hospitalizations, vocational problems, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, and early death.
10
Analyzed and justified whether the adults with nicotine dependence or psychiatric disorders consume 70% of all cigarettes smoked in the United States.
5
Used correct spelling, grammar, professional vocabulary, and APA format.
5
Total:
50

Informatics And Nursing 4

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A hospital is looking to implement an EHR. It has been suggested that an INS be hired. This position does not involve direct patient care and the administration is struggling with how to justify the position. How can this position be justified?

 

Using reference:

 

McGonigle, D., & Mastrian, K. (2015). Nursing informatics and the foundation of knowledge (3rd ed.).  Burlington, MA: Jones & Bartlett. (ISBN 978-1-284-04351-8)

>300 words, will be check for plagiarism by Turniton

HERE IS THE RESOURCES GIVEN:

Course Title:  B404 Nursing Informatics

Learning Goals/Outcomes

Upon completion, the student will be able to:

  • Analyze the sciences underpinning nursing informatics and their relationship to nursing informatics practice.
  • Discuss the evolving roles and competencies of nursing informatics practice.
  • Describe how clinical information technologies are and will impact nursing practice.
  • Explore how nurses can create and derive clinical knowledge from information systems.
  • Speculate on the future of nursing in the context of health informatics.

Required Resources

  • Read chapter 6, 7, 8 of your McGonigle and Mastrian textbook.

 

 

 

RECOMMENDED RESOURCES- WEBQUESTS

http://www.allianceni.org/ (Links to an external site.)

http://www.ahima.org/ (Links to an external site.)

https://www.amia.org/ (Links to an external site.)

https://www.ania.org/ (Links to an external site.)

http://www.himss.org/ (Links to an external site.)

http://www.imia-medinfo.org/new2/ (Links to an external site.)

http://www.imia.org/ni/ (Links to an external site.)

 

Mini Lecture

The IMIA-NI (Nursing Informatics: Special Interest Group of International Medical Informatics Association)definition, agreed at their General Assembly in Stockholm in 1997, and amended for clarity at the General Assembly in Seoul, 1998 defined Nursing Informatics as the integration of nursing, its information, and information management with information processing and communication technology, to support the health of people world-wide.

Evolution

The term “medical informatics” has its foundation with the French term “informatique” which concerns all the aspects of the computer as a tool for use in processing of information. The term “medical informatics” was used before “nursing informatics” and “health informatics”. Medical informatics is the use of computers for classification and retrieval of data and for the management health care information, enabling use to explore and better understand the informational and cognitive foundations of medicine3 (Blois, 1986).

In 1985 Hannah defined nursing informatics as the use of information technology by nurses carrying out their duties and which are in relation in relation to any function in the purview of nursing (as cited in Ball et al, 2000).

Graves and Corcoran (1989) state that nursing informatics is a “combination of computer science, information science, and nursing designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care.”

Romano (as cited in Ball et al., 2000) adds a further dimension to this definition by asserting that nursing informatics is “the application of the principles of information science and theory to the study, scientific analysis, and management of nursing information for the purpose of establishing a body of nursing knowledge”.

The ANA definition of nursing informatics. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge and wisdom in nursing practice.(ANA, 2008) Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision-making all roles and settings (ANA, 2008 p. 1). Aiding in their roles is what makes this definition role-oriented. Role oriented definitions seem to be the most complete of these NI definitions. They describe how the NI specialty functions under the broader scope of health informatics yet has specific components such as: differentiated practice, defined research, organizational representation, educational development, and credentialing (2008). As the definition has evolved, it has become more specific to nursing.

In summary, several definitions of nursing informatics have been proposed. The definition can be categorized as:

  • Technology-focused (Ball)
  • Conceptual-focused (Graves and Corcoran)
  • Role-orientated (ANA)

While the specialty of Nursing Informatics typically requires master’s level preparation, it is important for every nurse to have a good understanding and awareness of the concepts underlying nursing informatics. Both the ANA and the Essentials for Baccalaureate Education from AACN state that nursing students must have an understanding of nursing informatics.

According to ANA (2008), Nursing Informatics is a discipline-specific practice within the broader perspective of health informatics. NI has been recognized as a specialty for registered nurses in 1992. The focus of NI is on representation of nursing data, information, and knowledge; and the management and communication of nursing information within the broader context of health informatics.

Nursing informatics:

  • is nursing practice
  • adheres nursing values and beliefs
  • provides a practice base of the specialty of NI
  • produces new nursing knowledge
  • distinguishes a group of nursing practitioners
  • focuses on the phenomena of interest to nursing (patient, environment, health, nursing)
  • provide a domain-specific language, terminology and knowledge representation system.

Nursing Informatics is a specialty in nursing through it’s:

  • differentiated practice. In addition to the four phenomena of interest to the discipline of nursing, NI focuses on structure and algorithm of data, information, and knowledge used by nurses.
  • defined research program. Priorities for NI research are development of nursing languages and terminologies, databases for clinical information, patient as users of information technology, Telehealth, and issues of data privacy and confidentially.
  • organizational representation in international (e.g., IMIA) national (e.g., AMIA), regional, local level organizations providing opportunities for networking and professional development.
  • educational programs such as emerging NI graduate programs.
  • credentialing through ANCC

In addition the differentiation of NI as a specialty in nursing is also supported by:

NI’s own scientific nursing underpinnings

  • integration of concepts and tools from information science and computer science
  • application of Human computer Interaction (HCI) and ergonomics principles

The goals of Nursing Informatics are to improve health worldwide by optimizing nursing information management and communication.

The Informatics Nurse Specialist has at least a master’s degree in nursing informatics (system degree) and functions in the role of project manager, consultant, educator, researcher, development support, policy development or entrepreneurs related to nursing information technology application.

Although NI is considered a specialty practice within the discipline of nursing, some informatics competencies are required for all nurses. So is expected that a beginning nurse has fundamental computer literacy skills and information literacy skills related to patient care; the experienced nurse has proficiency in information management and communications in their area of practice such as community health, patient education, etc. The informatics Nurse Specialist is expected to have all the competencies outlined in the beginning and experienced nurse, and to demonstrate the competencies enumerated in the Standard of Practice (ANA, 2001), collaborate with other informaticists, and function within interdisciplinary environments such as health care, HCI, information science, and computer science.

Standards of Informatics

The American Nurses Association published the third iteration of its nursing informatics scope and standards of practice in 2008. This work reflects the significant evolution of the specialty from the original scope of practice statement published in 1994 and the first nursing informatics standards of practice in 1995. Although the definition of nursing informatics remains essentially unchanged from that presented in 2001, the inclusion of “wisdom” reflects today’s emerging mandate for evidence-based practice and decision support resources for the knowledge worker and emphasizes nursing informatics competencies and functional areas. Overall, it articulates the essentials of nursing informatics, its accountabilities and activities for both nursing informatics specialists and generalists. Its standards are those by which all nurses practice nursing informatics, and reflect and specify practice priorities and perspectives.

References

American Nurses Association. (2008). Scope and Standards of Nursing Informatics Practice. Washington, DC: American Nurses Publishing.

Ball, M. J., Hanna, K. J., Newbold, S. K., Douglas, J. V., & Donaldson, S. K. (Eds.). (2000). Nursing informatics: Where caring and technology meet (3rd ed.). New York, NY: Springer. Chapter 1

Graves, J. R., & Corcoran, S. (1989). The study of nursing informatics. Journal of Nursing Scholarship, 21(4), 227–231.

Hannah, K. J., Ball, M. J., & Edwards, M. J. A. (1994). Introduction to nursing informatics. New York, NY: Springer.

Course content is taken from NURS I630 developed by Josette Jones, Indiana University Indianapolis.

Learning Activities

Activities for This Lesson

 

A hospital is looking to implement an EHR. It has been suggested that an INS be hired. This position does not involve direct patient care and the administration is struggling with how to justify the position. How can this position be justified?

 

Self-Assessment

Lesson Evaluation Graded Assessments

  • Forum 3 (20 points)
  • Database Retrieval Assignment (15 points)

 

 

Case Analysis: Aviation Human Factors

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Your third case analysis is due at the end of this module. For this assignment, you will develop a formal 2-3 page paper/essay on aviation human factors. Your paper should follow the APA format and be grammatically sound and free of spelling errors. The paper should be written in the third person and double-spaced including a cover page with your name, date of submission, and the topic and appendix.

Review the Aviation Human Factors Case Analysis GuidelinesPreview the documentView in a new window for additional information about this assignment.

Examine the Case Analysis Rubric below to identify the qualities of an effective case analysis. Prior to submitting your assignment, save the file using the following naming convention: Activity6-5_Yourlastname. Note: This assignment is due at the end of this module.

Important: Retrieve the plagiarism report and use it as a source of feedback to revise your case analysis. In Module 7, you will post your revised case analysis for peer review in the Discussion Board.

ASCI 202 Introduction to Aeronautical Science

Case Analysis – Aviation Human Factors

 

Format – Two to three pages text (maximum, include a reference page; and a title page)

– Double-spaced lines

– Times New Roman 12 pitch

Process I. Review materials from outside sources regarding the case

II. Diagnose the case (identify the issue/problem, define the significance of the issue/problem)

III. “Size-up” the case (determine the influence of the issue/problem, decide what was done well, and identify

what could be improved)

IV. Provide recommendations (identify courses of action; what would you do differently?)

Develop a case analysis on this topic: Select a commercial aviation accident that was concluded to have resulted from pilot error. Determine the primary and any secondary human factors contributions to the accident.

Consider pilot training, organizational culture, organizational rules/policies, ergonomics, aircraft design limitations,

etc., when identifying an issue for your case analysis. As always, draw upon previous module knowledge to help

you conduct your analysis.

Refer to the assignment guides and rubric in the activity and ensure your case analysis conforms to the

assignment requirements. Use the rubric as a guide when completing this assignment. Remember to draw upon

previous module knowledge to help you conduct your analysis.

In order to receive full credit, assignments must be submitted by the due date. You may lose points for late

submissions. No submissions accepted after the last day of the module/week. Collectively, case analyses are

worth 30% of your course grade.

Upon submission, your work will automatically be evaluated through the plagiarism detection tool. Ensure your

work is entirely your own. Cite your sources!