TOPIC: DISCUSS NURSING INFORMATION MANAGEMANT UNDER THE

FOLLOWING SUB:

1. ELECTRONIC HEALTH RECORD

2. DATA ACCESS: HEALTH CARE DATA

3. INTEGRATION OF NURSING DATA

4. DOCUMENTATION OF PATIENT ASSESSMENT

5. DATA QUALITY, REPORTING AND SECURITY

6. INFORMATION RETRIEVAL SYSTEM

NAME: AMARI UJUNWA VIVIAN

COURSE TITLE: NURSING INFORMATION

COURSE CODE: GNS 113

(1) ELECTRONIC HEALTH RECORD

An electronic health record (EHR) is the systematized collection of
electronically stored patient and population health information in a digital
format. These records can be shared across different health care settings.
Records are shared through network-connected, enterprise-wide information
systems or other information networks and exchanges. EHRs may include a
range of data, including demographics, medical history, medication and
allergies, immunization status, laboratory test results, radiology images, vital
signs, personal statistics like age and weight, and billing information.

Sample view of an electronic health record

For several decades, EHRs have been touted as key to increasing quality of
care. EHR combines all patients' demographics into a large pool, which
assists providers in the creation of "new treatments or innovation in
healthcare delivery" to improve quality outcomes in healthcare. Combining
multiple types of clinical data from the system's health records has helped
clinicians identify and stratify chronically ill patients. EHR can also improve
quality of care through the use of data and analytics to prevent
hospitalizations among high-risk patients.

EHR systems are designed to store data accurately and to capture a patient's
state across time. It eliminates the need to track down a patient's previous
paper medical records and assists in ensuring data is up-to-date, accurate,
and legible. It also allows open communication between the patient and the
provider while providing "privacy and security. EHR is cost-efficient,
decreases the risk of lost paperwork, and can reduce risk of data replication
as there is only one modifiable file, which means the file is more likely up to
date. Due to the digital information being searchable and in a single file,
EMRs (electronic medical records) are more effective when extracting
medical data to examine possible trends and long-term changes in a patient.
The widespread adoption of EHRs and EMRs may also facilitate population-
based studies of medical records.

(2) DATA ACCESS: HEALTH CARE DATA

What is healthcare data?

Healthcare data refers to any information related to an individual's health

and medical history. This data can include a wide range of information, such
as: Personal Information: Name, age, gender, contact details, and other
demographic data. Medical History: Records of illnesses, surgeries,
medications, and treatments a person has undergone.

Diagnostic Information: Results of medical tests, laboratory reports, and

diagnostic imaging.

Treatment Plans: Information about the healthcare provider's recommended

course of action for managing a patient's health condition.

Insurance Information: Details related to health insurance coverage and

claims.

Health Behavior Information: Lifestyle factors, habits, and behaviors that can
impact health.

Why healthcare data is important for any organization?

Healthcare data is important for two main types of organizations. The first
category comprises healthcare organizations, including hospitals, clinics, and
other healthcare facilities. The second category involves government health
departments. While both fall under the umbrella of the healthcare sector,
their utilization of healthcare data differs significantly. These organizations,
despite being integral parts of the healthcare landscape, employ healthcare
data in distinct ways to fulfill their respective roles and responsibilities

Healthcare Organizations:
Informed Decision-Making:

Healthcare data provides valuable insights that enable informed decision-

making for healthcare organizations. Analyzing patient data, treatment
outcomes, and resource utilization helps optimize processes and improve
overall efficiency.

Enhanced Patient Care:

Access to healthcare data allows providers to deliver more personalized and

effective patient care. It aids in creating tailored treatment plans, monitoring
patient progress, and identifying preventive measures.

Efficient Operations:

Organizations can optimize their operations by leveraging healthcare data.

This includes managing resources effectively, streamlining workflows, and
identifying areas for improvement in administrative and clinical processes.

Research and Development:

Healthcare data serves as a valuable resource for medical research.

Organizations can use aggregated and anonymized data to identify trends,
conduct epidemiological studies, and contribute to advancements in medical
knowledge and technology.

Quality Improvement Initiatives, Risk Management, and Fraud Detection:

Regular analysis of healthcare data allows organizations to assess the quality

of care provided. This facilitates the implementation of quality improvement
initiatives to enhance patient outcomes and satisfaction. Simultaneously, it
helps in identifying potential risks, such as disease outbreaks or patient
safety concerns, and aids in detecting fraudulent activities, ensuring the
integrity of healthcare systems.

Regulatory Compliance:
Healthcare organizations must adhere to various regulations and standards,
such as HIPAA (Health Insurance Portability and Accountability Act). Proper
management of healthcare data ensures compliance with these regulations,
preventing legal and financial repercussions.

Population Health Management:

Healthcare data supports population health management strategies by

allowing organizations to identify and address the health needs of specific
groups. This proactive approach helps in preventing diseases and improving
overall community health.

Patient Engagement and Empowerment:

Access to their healthcare data empowers patients to actively participate in

their care. Organizations can use data-sharing platforms to engage patients
in their health management and promote a collaborative approach to
healthcare.

Cost Optimization:

By analyzing healthcare data, organizations can identify areas where costs

can be optimized without compromising the quality of care. This includes
resource allocation, inventory management, and identifying cost-effective
treatment options.
 (3) INTEGRATION OF NURSING DATA

Healthcare data integration is a critical component of modern healthcare

systems. Combining data from disparate sources, such as EHRs and medical
devices, allow providers to gain a complete picture of patient health and
streamline workflows.

Data Integration Can Help The Healthcare Industry Enjoy Significant Savings

The Rise in Data Sources and the Importance of Healthcare Data Integration

The healthcare industry generates billions of terabytes of data from various

sources. Electronic Health Records (EHRs) and Electronic Medical Records
(EMRs) are primary sources of patient data. This data is mostly available in a
structured format and easily accessible.

However, there are also secondary data sources, including telemedicine and
insurance systems, pharmacy management systems, patient portals, social
media, and more. The real task is to ingest, process, and consolidate this
data and generate timely insights.

Healthcare data integration involves combining data from various

touchpoints into a single, consolidated data repository. This data is cleansed
and transformed during the process to be usable for reporting and analytics,
so healthcare practitioners can make informed, data-driven decisions.

Here are some prominent use cases of healthcare data integration:

This data may include, but is not limited to, a patient’s medical history, EHR
records, insurance claims data, demographic data, lab results, and imaging
systems. Healthcare organizations may also enrich this data with information
from third-party providers.

A holistic view of the data in a unified platform enables healthcare

practitioners to identify patterns and trends in patient behavior and, as a
consequence, devise better diagnosis and preventative strategies as well as
deliver personalized care.

Crisis Response
The COVID-19 pandemic highlighted the crucial role of health data
integration in crisis response. Consolidated, high-quality data allows
healthcare organizations to make informed crisis-response decisions—
ensuring optimal care for patients and safety for frontline workers.

Healthcare organizations can quickly identify at-risk populations, track the

spread of the virus, plan for effective vaccine distribution, and coordinate
with other organizations to handle critical situations effectivel.

Fraud Detection

Fraudulent activities in healthcare can take various forms, including identity

fraud, where a patient uses multiple identities to access medical care;
service-level fraud, such as overbilling for provided services; and insurance-
level fraud, such as filing claims for services not received.

A single source of truth allows healthcare organizations to apply data mining

techniques to effectively detect and prevent fraud.

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Data Integration Challenges in Healthcare

Healthcare data wields enormous power, but the sheer volume and variety of
this data pose various challenges. Here are some data integration challenges
that prevent healthcare professionals from unlocking valuable insights:

Data Silos and Lack of Interoperability

Data silos occur when data is stored in isolated systems that don’t
communicate with one another. These silos are quite common—especially
when healthcare providers use different EHR/EMR systems that are
incompatible with each other.

Moreover, traditional, legacy systems make it difficult to integrate with

newer, cloud-based systems, exacerbating the challenge of EHR/EMR data
integration. The lack of interoperability among healthcare systems and
providers is another aspect that makes real-time data sharing difficult.

Lack of Standardization
The lack of data standardization makes it difficult for healthcare providers to
consolidate data from various sources. Data without standardization can
result in duplicate records, system failure, and inaccurate insights, which can
affect patient care.

The use of different data formats by healthcare providers hinders

communication and data sharing between systems, which leads to and data
quality issues. Lack of data standardization mainly affects data integration
and reusability.

Data Privacy and Security

Medical providers face significant data privacy and security challenges when
integrating healthcare data. Patient health information is highly sensitive and
requires robust protection from unauthorized access and data breaches.

Healthcare systems increasingly rely on digital channels and collect data, so

it’s imperative to maintain compliance with data privacy regulations. A 2022
report shows over 595 health data breaches occurred in the last three years,
exposing over 40 million patient records.

Therefore, healthcare organizations must implement strict measures to

protect confidential patient information while integrating data from various
systems.

Here are some data integration strategies to efficiently address healthcare

data challenges:

Switch to a Cloud Data Warehouse

Cloud data warehouses are built to handle high data volumes and variety. A
large cloud solution, such as Amazon Redshift and Snowflake, can serve as a
centralized repository for high-velocity data streams. Cloud data warehouses
can offer more powerful computing capabilities for faster insights and
improved business intelligence. Moreover, they are also easily scalable and
offer unlimited storage capacity on the go.

Identify Data Sources

The key to successful data integration implementation is knowing where all

critical data resides. For healthcare providers, EHR systems contain the most
important data, but there are other data sources, internal and external, that
must be identified and documented.
Implement Standards Such as FHIR and HL7

Using industry standards such as Fast Healthcare Interoperability Resources

(FHIR) and Health Level Seven International (HL7) can facilitate the
healthcare data integration process.

These standards provide a common language for data exchange, allowing

healthcare organizations to share patient data easily.

Prioritize Data Privacy and Security

Robust security protocols and regular security audits are essential to ensure
compliance with relevant data privacy laws and regulations such as Health
Insurance Portability and Accountability Act (HIPAA) and General Data
Protection Regulation (GDPR).
 (4) DOCUMENTATION OF PATIENT ASSESSMENT

Introduction to Patient Assessment and Documentation Patient assessment is

the systematic collection, analysis, and interpretation of data about a
patient's health status, needs, preferences, and goals. Documentation is the
recording of the patient assessment data and the nursing interventions,
outcomes, and evaluations in a clear, accurate, timely, and legal manner.
Patient assessment and documentation are essential for providing safe,
effective, and individualized nursing care, as well as for communicating with
other health care providers, ensuring continuity of care, evaluating the
quality of care, and meeting legal and ethical standards.
 (5) DATA QUALITY, REPORTING AND SECURITY

Data quality criteria can include dimensions such as accuracy, completeness,

timeliness, relevance, consistency, and validity. You can use these criteria to
set standards, measure performance, and identify gaps or errors in your
data. For example, you can use data quality indicators (DQIs) to monitor and
report on the status of your data quality. You can also use data quality tools
(DQTs) to validate, clean, or enrich your data.

Implement data security policies

Data security is not only a technical issue, but also a legal and ethical one.
You need to comply with the relevant data protection laws and regulations in
your region, such as the General Data Protection Regulation (GDPR) in the
European Union or the California Consumer Privacy Act (CCPA) in the United
States. You also need to respect the rights and preferences of your data
subjects, such as their consent, access, or deletion requests. To implement
data security policies, you need to establish roles and responsibilities, define
data classification and retention rules, and enforce data encryption and
authentication methods.

Adopt data quality and security frameworks

You don't have to reinvent the wheel when it comes to data quality and
security. You can adopt existing frameworks and standards that provide best
practices and guidelines for managing and improving your data. For
example, you can use the ISO 8000 series of standards for data quality
management, which cover aspects such as data governance, data
architecture, data operations, and data assessment. You can also use the ISO
27000 series of standards for information security management, which cover
aspects such as risk assessment, security controls, audits, and compliance

Train and educate your data users

Data quality and security are not only the responsibility of your data
professionals, but also of your data users. You need to train and educate
your data users on how to handle and use data properly and safely. You can
provide them with data quality and security awareness programs, manuals,
or guides that explain the principles, policies, and procedures of your data
management. You can also encourage them to follow data quality and
security best practices, such as verifying data sources, checking data
accuracy, reporting data issues, and protecting data privacy.

Our analysts and daily data users must know how to spot data that is not
valid. Validated data is formatted properly and within an acceptable range of
values. Further, the data in your set should be accurate and consistent.
Invalid or bad data leads to inaccurate analysis and inaccurate insights,
which can lead to bad decisions by senior leaders. It's critical for data users
to know the difference.

Monitor and review your data quality and security

Data quality and security are not static, but dynamic. They can change over
time due to various factors, such as new data sources, new business
requirements, new technologies, or new threats. You need to monitor and
review your data quality and security regularly and continuously, using
metrics, reports, feedback, or audits. You also need to update and improve
your data quality and security processes, tools, and frameworks based on
the results of your monitoring and review. You can use a continuous
improvement cycle, such as the Plan-Do-Check-Act (PDCA) model, to guide
your actions.

An information retrieval process begins when a user enters a query into the
system. Queries are formal statements of information needs, for example
search strings in web search engines. In information retrieval, a query does
not uniquely identify a single object in the collection. Instead, several objects
may match the query, perhaps with different degrees of relevance.

An object is an entity that is represented by information in a content

collection or database. User queries are matched against the database
information. However, as opposed to classical SQL queries of a database, in
information retrieval the results returned may or may not match the query,
so results are typically ranked. This ranking of results is a key difference of
information retrieval searching compared to database searching.
 (6) INFORMATION RETRIEVAL SYSTEM

The concept of Information Retrieval System (IRS) is self-explanatory from

the terminological point of view and refers to a ‘system which retrieves
information. IRS is concerned with two basic aspects: (i) How to store
information, and (ii) How to retrieve information.

One may simply denote such a system as one that stores and retrieves
information. IRS is comprised of a set of interacting components, each of
which is designed to serve a specific function for a specific purpose. All these
components are interrelated to achieve a goal. The concept of IR thus is
based on the fact that there are some items of information which have been
organized in a suitable order for easy retrieval.

An information retrieval system is designed to analyze, process and store

sources of information and retrieve those that match a particular user’s
requirements. Modern information retrieval systems can either retrieve
bibliographic items or the exact text that matches a user’s search criteria
from a stored database of documents. IRS originally meant text retrieval
systems as they were dealing with textual documents. Modern information
retrieval systems deal not only with textual information but also with
multimedia information comprising text, audio, images and video. Thus,
modern information retrieval systems deal with storage, organization and
access to text, as well as multimedia information resources.

Thus, an IR system is a set of rules and procedures, for performing some or

all of the following operations:

a) Indexing (or constructing of representations of documents);

b) Search formulation (or constructing of representations of information
needs);
c) Searching (or matching representations of documents against
representations
of needs); and

d) Index language construction (or generation of rules of representation)

So information retrieval is collectively defined as a “science of search” or a
process, method and procedure used to select or recall, recorded and/or
indexed