Health Information Management

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Information Management in the Health Care System
In the health care system communication among various providers and disciplines is a very important factor contributing to the quality and standard of care. Communication often takes place in person but more frequently is part of a data collection system. Electronic health care records provide a means to interchange thoughts, opinions, and overall information. Studies have shown that attention to communication style and computer proficiency plays a role in health care delivery. According to the American Nurses Association (2010) the use of a standardized nursing language for documentation of nursing care is both vital to the nursing profession and to direct nursing care. As of 2008 the American …show more content…
Teams of nurses from all areas of Baptist Health form a committee that focuses on an action plan to use recommendations from the Health Information and Management System Society (HIMSS). Using the TIGER initiative there are three parts to the implementation of nursing informatics, basic computer competencies, information literacy and information management (Fetter, 2009). Of the ten nursing specific terminologies, Baptist Health uses the Nursing Outcomes Classification. This decision was based upon the drive for patient-centered care and an assessment that is patient focused. The Affordable Care Act also influenced this decision as it has begun to tie reimbursement with patient outcomes. Specifically Baptist Health uses the Outcomes-Driven Cerner-Clairvia Nursing Acuity methodology when implementing NOC in various specific practice areas. Both the NOC combined with the Cerner-Clairvia methodology give real time data based on the bedside nurses clinical …show more content…
This methodology integrates with and complements pre-existing electronic clinical documentation. This is accomplished by an HL-7 data connection that allows an organization’s electronic medical record to communicate with the acuity system (Laird-Maddox et al., 2014). In addition to the outcome sets developed from NOC, the Cerner Clairvia Core Data Set is also used to identify data required from the electronic health documentation to insure accurate and reliable acuity scores are made (Laird-Maddox et al., 2014). Specifically this additional data set tries to prevent gaps with what is charted routinely and consistently against what is required. The Outcomes-Driven Patient Acuity system is both evidence-based and holistic in nature. The Baptist Health Nursing Informatics Committee reviews data sets, flow charts, screens, and fields that nurses use for electronic documentation for each practice area and identifies the most frequently charted data and the best indicators of patient’s clinical status. This generates an understanding or a catalog of data that must be included in the acuity audit. All of these measures ensure that the electronic data is implemented and the NOC terminology developed for meaningful
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