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Nursing Informatics: Introduction to Concepts and Health Information TechnologiesTerminologies and StandardsSensmeier begins Chapter 7 with the profound statement, “standards are the foundation to the development, implementation, and exchange of electronic health records” (2015, p. 101). The chapter author continues that “the effectiveness of healthcare delivery is dependent on the ability of clinicians to securely access health information when and where it is needed” (2015, p. 101). Sensmeier notes that data standards reduce ambiguity in communication.Hammonds (2005) identified that standards are created by including A group of interested parties comes together and agrees upon a standardThe government sanctions a process for standards to be developed Marketplace completion and technology adoption introduce a de facto standardA formal consensus is used by a standards development organization (SDO)Institute of Electrical and Electronics Engineers (IEEE) provides more information regarding the standards development process. The IEEE provides this informative flowchart (Figure 1) of the process.Figure 1 The IEEE depiction of the standards development process presented as flowchart (IEEE, 2018) Note. Standard development process.This flowchart illustrates the length of time to develop a standard. The process is lengthy. IEEE notes a standard will undergo multiple iterations. IEEE notes (2018) “It is important to remember that standards are “living documents", which may initially be published and iteratively modified, corrected, adjusted and/or updated based on market conditions and other factors” (2018, para. 8). Sensmeier identifies the following standards Transport Standards Accredited Standards Committee X12N/InsuranceInstitute of Electrical and Electronic EngineersNational Electrical Manufacturers Association World Wide Web ConsortiumCommunication ProtocolsVocabulary Standards Current Procedural TerminologyInternational Statistical Classification of Diseases and Related Health Problems: Ninth Revision and Clinical ModificationInternational Statistical Classification of Diseases and Related Health Problems: Tenth RevisionNursing and other Domain Specific TerminologiesRxNormUnified Medical Language SystemContent StandardsAmerican Society for Testing and MaterialsClinical Data Interchange Standards ConsortiumHealth Level Seven (HL7)International Health Terminology Standards Development OrganizationLogical Observational Identifiers Names and Codes (LOINC)National Council for Prescription Drug ProgramsNational Uniform Claim Committee Recommended Data Set for a Noninstitutional ClaimSecurity StandardsHIPAA Security Standards for the Protection of Electronic Health Information at 45 CFR Part 160 and Part 164, Subparts A and CISO IEC 27002:2005 StandardImplementation GuidesSensmeier presents a succinct overview regarding standardization and harmonization. The chapter author states (2015, p. 107) “It has become clear to both public and private sector standards development efforts that no one entity has the resources to create an exhaustive set of health data standards that will meet all needs. New emphasis is being placed on leveraging and harmonizing existing standards to eliminate the redundant and siloed efforts that have contributed to a complex, difficult to navigate health data standards environment. Advances are being made to in the areas of standard harmonization through the coming together of industry groups to accelerate and streamline the standards development and adoption process.” A brief overview of the major national and international organizations is provided for the following:American National Standards InstituteEuropean Technical Committee for StandardizationHealth IT Standards CommitteeIntegrating the Healthcare Enterprise (IHE)International Organization for StandardizationObject Management GroupPublic Health Data Standards ConsortiumImportantly, a synopsis is provided for the ONC Standards and Interoperability (S&I) Framework. The S&I Framework was launched in 2011. Each S&I Initiative typically includes the following:Development of clinically oriented user stories and robust user casesHarmonization of interoperability specifications and implementation guidanceProvision of real-world experience and implementer support through new initiatives, workgroups, and pilot projectsMechanisms for feedback and testing of implementation often in conjunction with ONC partners such as NISTInterestingly, Sensmeier discusses the business value of health care data standards. The author recognizes that “other state holders for health IT include software vendors or suppliers, software implementers, and users. “Defining clear business measures will help motivate the advancement and adoption of interoperable health IT systems, thus ensuring the desired outcomes can be achieved (Sensmeier, 2015, p. 112). Notably, “The importance of data standards to enhancing the quality and efficiency of healthcare delivery and improving health outcomes is being recognized by national and international leadership” (Sensmeier, 2015, p. 111). Sensmeier continues “A standardized nursing language is necessary so that nursing knowledge can be represented and communicated consistently among nurses and other healthcare providers” (2015, p. 2011). Hardiker, Saba, and Kim continue the discussion of standards in Chapter 8. The chapter authors bring attention to standardized nursing terminologies. Hardiker, Saba, and Kim cite numerous authors in the following quotation “To become visible nursing needs to electronically document nursing practice using a standardized nursing terminology with coded concepts in order to measure the effectiveness of their care delivery and thus generate the evidence (2015, p.. 115). It is further explained that standardized nursing terminologies are needed to Provide valid clinical care dataAllow data sharing across HIT and EHR systemsSupport evidence-based decision makingFacilitate evaluation of nursing processesPermit the measurement of outcomesNursing has thirteen (13) recognized terminologies. The terminologies include:Nursing Minimum Data SetNursing Management Minimum Data SetClinical Care Classification (CCC) SystemInternational Classification of Nursing PracticeNANDANursing Intervention ClassificationNursing Outcome ClassificationOmaha SystemPerioperative Nursing Data SetABC CodesLogical Observation Identifiers Names and CodesSystematic Nomenclature of Medicine-Clinical TermsThe chapter authors importantly describe ISO 18104:2003, Integration of a Reference Terminology Model for Nursing. The terminology model covers both Nursing Diagnoses and Nursing Actions. Development of the reference model was attributed to harmonization with other standards and to be consistent with the goals and objectives of other health terminology models. The authors note the standard is not to be of direct benefit to the practicing nurse but to those who develop coding systems. The chapter concludes with the important statement, “Interoperability is a prerequisite to meeting the information demands of today’s complex healthcare, management, and nursing environment (Hardiker, Saba, Kim, 2015, p. 125). Learning ObjectivesDiscuss the need for health data standardsDescribe the standards development process and related organizationsDelineate the importance of health information exchange and interoperabilityDescribe the current health data standards initiativesExplore the business value of health data standardsDefine “standardized nursing terminology”Describe the impact of terminologies on nursingDescribe the features of advanced nursing terminology systemsActivities Read and reviewSensmeier, J. (2015). Chapter 7 Health data standards: Development, harmonization, and interoperability. In V. Saba & K. McCormick (Eds.), The essentials of nursing informatics (6th ed., pp. 101-113). McGraw-Hill. Hardiker, N. R., Saba, V. K., & Kim, T. Y. (2015). Chapter 8 Standardized nursing terminologies. In V. Saba & K. McCormick (Eds.), The essentials of nursing informatics (6th ed., pp. 115-129). McGraw-Hill. MBL Technologies, Clinovation. (2017). Standard nursing terminologies: A landscape analysis. The Office of the National Coordinator for Health Information Technology. https://www.healthit.gov/sites/default/files/snt_final_05302017.pdfASSIGNMENTAs an individual, explore the Clinical Care Classification (CCC) System available at (www.clinicalcareclassification.com or www.sabacare.com). Review the website Home, About, Framework, and Tools. From Tools dropdown menu select Code Builder. Step 1. Assessment: Select a ComponentFrom the list select O Self Care Step 2. Select a Major DiagnosisFrom the list select Code 38.0 Self Care Deficit Impaired ability to maintain oneselfStep 3. Select a Sub-DiagnosisFrom the list select Code 38.1 Activities of Daily Living (ADLs) Alteration Change in modification of ability to maintain oneselfStep 4. Select an Expected OutcomeSelect Code 1 Improve Condition will change over timeStep 5. Select an InterventionSelect Code 43 Personal Care Actions performed to care for oneselfStep 6. Select a Sub-InterventionSelect Code 43.1 which refers to the sub-intervention code: Activities of Daily Living (ADLs) and may be described as: Personal activities to maintain oneselfStep 7. Select ActionSelect Code 3 Teach/Educate/Instruct/Supervise Action educating patient or caregiverStep 8. Select Possible Actual OutcomeSelect Code 1 ImprovedCondition changed and/or recoveredStep 9. Take a screen print of the completed planBe sure to submit the screen printLabel the screen print as a figure following APAWrite a 150-200 summary of what did you learn about using a standardized terminology to create a plan of care. Be sure to reference the CCC. Write a 150-200 word summary of what nursing or other terminologies are used in your organization? How are the terminologies used?Submit Use a cover page and headings following APA to structure the submission. Develop a plan of care for Self Care using CCC. Label the screen print as a figure following APA style. Write a 150-200 summary of what did you learn about using a standardized terminology to create a plan of care. Be sure to reference the CCC and the website. Write a 150-200 word summary of what nursing or other terminologies are used in your organization? How are the terminologies used? If no terminologies are used what would you recommend? Use references.Submit as one Word document. Grading Rubric ActivityPoints PossiblePoints EarnedCommentsDevelop a plan of care for Self-Care using CCC35Write a 150-200 summary of what did you learn about using a standardized terminology to create a plan of care. Be sure to reference the CCC and the website. Label the screen print as a figure following APA style. 25Write a 150-200 word summary of what nursing or other terminologies are used in your organization? How are the terminologies used? If no terminologies are used what would you recommend? Use references.25APA in the text references 1APA Reference List 1Headings, Readability, Grammar, Spelling 13Submit Use a cover page and headings following APA to structure the submission. Develop a plan of care for Self-Care using CCC. Label the screen print as a figure following APA style. A 150-200 summary of what did you learn about using a standardized terminology to create a plan of care. Be sure to reference the CCC and the website. Write a 150-200 word summary of what nursing or other terminologies are used in your organization? How are the terminologies used? If no terminologies are used what would you recommend. Use references.Submit as one Word document. 0Total 100
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