s3.amazonaws.com · 3.6 Patient Protection and Affordable Care Act ... 4.7 Supporting Decisions for...

Rocky Reston, MD, PhD & Corinn Pope, PMP, MS

Clinical B o a r d R e v i e w

2 n d E d i t i o nPass the Exam the First Time

Informatics

• C l i n i c a l D a t a S t a n d a r d s

• M a n a g i n g C h a n g e

• C l i n i c a l I n f o r m a t i o n S y s t e m s

• T h e H e a l t h S y s t e m

• C l i n i c a l D e c i s i o n M a k i n g

• H e a l t h c a r e I T R e g u l a t i o n s

a n d m o r e . . .

Clinical Informatics Board Review, © 2016, InformaticsPro, Inc.

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Clinical Informatics Board Review Pass the Exam the First Time, Second Edition

By

Corinn Pope, PMP

Rocky Reston, MD, PhD


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Copyright © 2016 by InformaticsPro, Inc. All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2015 Second Printing, 2016 ISBN 978-0-9863155-3-4 InformaticsPro San Diego, CA www.informaticspro.com


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Table of Contents 1. Exam Details .............................................................................................................................. 1

1.1 Topics Covered ..................................................................................................................... 1 1.2 Requirements for Certification ............................................................................................. 2

1.2.1 Licensure .................................................................................................................................................. 3 1.2.2 One of the Following “Pathways” to Certification ........................................................................... 3

1.3 Exam Day ............................................................................................................................. 5 1.3.1 The Exam Format .................................................................................................................................. 5 1.3.2 Registering for the Exam ....................................................................................................................... 6 1.3.3 The Exam Location ................................................................................................................................ 6

2 Clinical Informatics Overview ..................................................................................................... 7 2.1 What is a Clinical Informaticist? .......................................................................................... 8 2.2 Informatics History ............................................................................................................... 8

2.2.1 A History of the Clinical Informatics Subspecialty ........................................................................... 9 2.3 Domains of Informatics ........................................................................................................ 9

2.3.1 Translational bioinformatics ............................................................................................................... 10 2.3.2 Imaging informatics ............................................................................................................................. 10 2.3.3 Public health informatics ..................................................................................................................... 10 2.3.4 Clinical informatics ............................................................................................................................... 10

2.4 Informatics as a Career ........................................................................................................ 11 2.4.1 Interest Groups ..................................................................................................................................... 11 2.4.2 Professional Organizations ................................................................................................................. 12 2.4.3 Professional Certifications ................................................................................................................... 13

2.5 Current and Future Challenges for Informatics .................................................................. 13 2.5.1 Interoperability ...................................................................................................................................... 13 2.5.2 Usability .................................................................................................................................................. 13 2.5.3 Patient engagement .............................................................................................................................. 14 2.5.4 Personalized medicine .......................................................................................................................... 14 2.5.5 Ubiquitous care ..................................................................................................................................... 15

2.6 Key Concepts, Models, and Theories in Informatics .......................................................... 15 2.7 Clinical Informatics Literature ............................................................................................ 16

2.7.1 What is Fit for Peer Review? .............................................................................................................. 16 2.7.2 Critically Analyzing Literature ............................................................................................................ 17

2.8 International Clinical Informatics Practices ....................................................................... 17 2.9 Ethics in Clinical Informatics .............................................................................................. 18

2.9.1 Professional Ethical Conduct ............................................................................................................. 18 2.9.2 Conflict of Interest ............................................................................................................................... 19


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2.9.3 Hippocratic Oath .................................................................................................................................. 19 2.9.4 FTC Fair Information Practice ........................................................................................................... 19 2.9.5 Human Rights ....................................................................................................................................... 20 2.9.6 Ethical Concepts ................................................................................................................................... 20 2.9.7 Ethical Theories .................................................................................................................................... 21 2.9.8 Ethical Decision Making ..................................................................................................................... 23 2.9.9 Current Topics in Bioethics ................................................................................................................ 24

2.10 Legal and Regulatory Issues ............................................................................................ 26 2.10.1 HIPAA ................................................................................................................................................. 26 2.10.2 PPACA ................................................................................................................................................. 27 2.10.3 HITECH .............................................................................................................................................. 27 2.10.4 Joint Commission Standards ............................................................................................................ 27

2.11 Review Questions ............................................................................................................. 28 2.12 Recommended Reading ................................................................................................... 30

3 The Health System ..................................................................................................................... 31 3.1 Determinants of Individual and Population Health ........................................................... 31 3.2 Domains of the Health System ............................................................................................ 31

3.2.1 The Healthcare Delivery System ........................................................................................................ 32 3.2.2 Healthcare Organizational Structure ................................................................................................. 35 3.2.3 Accreditation ......................................................................................................................................... 36 3.2.4 Licensing & Credentialing ................................................................................................................... 36 3.2.5 Continuum of Care ............................................................................................................................... 37 3.2.6 Patient Centered Medical Home ........................................................................................................ 38 3.2.7 Accountable Care Organizations ....................................................................................................... 39 3.2.8 Public Health ......................................................................................................................................... 40 3.2.9 Clinical Research ................................................................................................................................... 41 3.2.10 Health Education for Professionals ................................................................................................ 42 3.2.11 Personal Health .................................................................................................................................. 43 3.2.12 Personal Health Information ............................................................................................................ 43 3.2.13 Personal Health Maintenance ........................................................................................................... 43 3.2.14 Occupational Health .......................................................................................................................... 44

3.3 Data, Information, and Knowledge Flows ......................................................................... 44 3.3.1 Data and Information Flow ................................................................................................................ 44

3.4 Policy and Regulatory Framework ..................................................................................... 46 3.5 HITECH ............................................................................................................................. 46

3.5.1 Meaningful Use as a Part of HITECH .............................................................................................. 46 3.5.2 Meaningful Use Stages ......................................................................................................................... 47


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3.5.3 Meaningful Use in 2015 ....................................................................................................................... 47 3.5.4 Certified EHR Technology ................................................................................................................. 49 3.5.5 Registering and Attesting to Meaningful Use ................................................................................... 49 3.5.6 Hardship Extensions ............................................................................................................................ 52 3.5.7 Clinical Quality Measures & Reporting ............................................................................................. 52

3.6 Patient Protection and Affordable Care Act (PPACA) ....................................................... 54 3.6.1 The Sunshine Act ................................................................................................................................. 54

3.7 Health Insurance Portability and Accountability Act (HIPAA) ........................................ 54 3.7.1 HIPAA Privacy Rule & Security Rule ............................................................................................... 55 3.7.2 PHI and HIPAA ................................................................................................................................... 55 3.7.3 Noncompliance ..................................................................................................................................... 55 3.7.4 Covered Entities Under HIPAA ........................................................................................................ 56 3.7.5 Privacy Rule Principles Applicable to Health IT ............................................................................. 56 3.7.6 Access to PHI Under the Privacy Rule ............................................................................................. 58 3.7.7 The Privacy Rule and Personal Health Records .............................................................................. 59 3.7.8 Additional HIPAA Considerations .................................................................................................... 60 3.7.9 HIPAA Breach Notification Rule ...................................................................................................... 61 3.7.10 Physician Quality Reporting System (PQRS) ................................................................................. 61

3.8 Food and Drug Administration Safety and Innovation Act (FDASIA) .............................. 62 3.9 Health Economics and Financing ..................................................................................... 62

3.9.1 Organizational Finance ........................................................................................................................ 62 3.9.2 Financing and Payments in the Health Care System ...................................................................... 65

3.10 Economics ........................................................................................................................ 67 3.10.1 Performing Economic Evaluations ................................................................................................. 69 3.10.2 Cost Effectiveness & Cost Benefit Analysis .................................................................................. 69 3.10.3 Markets Within Health Care ............................................................................................................. 70 3.10.4 Healthcare Spending .......................................................................................................................... 71

3.11 Forces Shaping the Healthcare Delivery System ............................................................. 72 3.12 Healthcare Quality ............................................................................................................ 74

3.12.1 Measures of Quality ........................................................................................................................... 76 3.12.2 Performance Management ................................................................................................................ 77 3.12.3 Utilization Management .................................................................................................................... 78 3.12.4 Risk Management ............................................................................................................................... 78

3.13 Review Questions ............................................................................................................. 80 3.14 Suggested Reading ........................................................................................................... 84

4 Clinical Decision Making and Care Process Improvement ...................................................... 85 4.1 The Nature and Cognitive Aspects of Human Decision Making ..................................... 85


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4.1.1 Decision Making ................................................................................................................................... 86 4.1.2 Medical Decision Making .................................................................................................................... 87

4.2 Decision Science ................................................................................................................. 89 4.2.1 Decision Analysis .................................................................................................................................. 90 4.2.2 Probability Theory ................................................................................................................................ 91 4.2.3 Utility and Preference Assessment ..................................................................................................... 94 4.2.4 Cost Effectiveness Analysis ................................................................................................................ 96 4.2.5 Test Characteristics .............................................................................................................................. 97

4.3 Application of Clinical Decision Support .......................................................................... 101 4.3.1 Knowledge-Based vs. Non-Knowledge Based CDSS ................................................................. 101 4.3.2 The Five Rights Model of CDS ....................................................................................................... 101 4.3.3 Features of CDSS .............................................................................................................................. 102 4.3.4 Benefits and Drawbacks ................................................................................................................... 102 4.3.5 Types of Decision Support .............................................................................................................. 103 4.3.6 Users of Decision Support ............................................................................................................... 104

4.4 Implementing, Evaluating, and Maintaining Clinical Decision Support ......................... 105 4.4.1 Implementation .................................................................................................................................. 105 4.4.2 Evaluation ........................................................................................................................................... 106 4.4.3 Maintenance ........................................................................................................................................ 106

4.5 Transforming Knowledge into CDS Tools ........................................................................ 107 4.5.1 Knowledge Generation ..................................................................................................................... 108 4.5.2 Knowledge Acquisition .................................................................................................................... 109 4.5.3 Knowledge Modeling ........................................................................................................................ 110 4.5.4 Knowledge Representation .............................................................................................................. 110 4.5.5 Knowledge Management and Maintenance .................................................................................. 112

4.6 Legal, Ethical and Regulatory Issues ................................................................................ 113 4.6.1 Ethical Questions in CDS ................................................................................................................ 113 4.6.2 Legal and Regulatory Issues ............................................................................................................. 114 4.6.3 FDA Regulation of CDS .................................................................................................................. 114 4.6.4 CDS In Meaningful Use ................................................................................................................... 114 4.6.5 CDSS Quality ..................................................................................................................................... 115 4.6.6 CDSS Safety ........................................................................................................................................ 115

4.7 Supporting Decisions for Population of Patients .............................................................. 116 4.8 Suggested Reading ............................................................................................................ 122 4.9 Review Questions .............................................................................................................. 118

5 Evidence Based Patient Care ................................................................................................... 123 5.1 Evidence-Based Medicine Sources ................................................................................... 123


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5.2 Evidence Grading .............................................................................................................. 124 5.2.1 AHRQ USPSTF Grading System ................................................................................................... 124 5.2.2 AHRQ USPSTF Certainty Levels ................................................................................................... 125 5.2.3 Additional Grading Guidelines and Frameworks ......................................................................... 126

5.3 Clinical Guidelines ............................................................................................................. 127 5.3.1 Developing Guidelines ..................................................................................................................... 127 5.3.2 Developing Guidelines ..................................................................................................................... 129 5.3.3 Sources of Clinical Guidelines ......................................................................................................... 130 5.3.4 Grading Evidence and Clinical Guidelines .................................................................................... 131

5.4 Implementation of Guidelines as Clinical Algorithms ...................................................... 131 5.4.1 Implementing and Evaluating Guidelines ..................................................................................... 132

5.5 Information Retrieval ......................................................................................................... 132 5.5.1 Information Retrieval Terminology ................................................................................................ 133 5.5.2 Indexing .............................................................................................................................................. 134 5.5.3 Term Frequency-Inverse Document Frequency .......................................................................... 134 5.5.4 Retrieving Information ..................................................................................................................... 135 5.5.5 Mathematical & Property Dimensions of Information Retrieval Models ................................ 135 5.5.6 Information Retrieval Performance ................................................................................................ 136 5.5.7 Search Skills ........................................................................................................................................ 137 5.5.8 Foreground Vs. Background Questions ........................................................................................ 137 5.5.9 Levels of Evidence Pyramid ............................................................................................................ 138 5.5.10 Meta-Analyses .................................................................................................................................. 138 5.5.11 Critical Analysis of Biomedical Literature ................................................................................... 139

5.6 Review Questions .............................................................................................................. 142 5.7 Suggested Reading ............................................................................................................ 145

6 Workflow Analysis, Process Redesign, and Quality Improvement ......................................... 146 6.1 Methods of Workflow Analysis .......................................................................................... 146

6.1.1 Documenting Current Workflows .................................................................................................. 147 6.1.2 Developing Flowcharts ..................................................................................................................... 148 6.1.3 Workflow Analysis ............................................................................................................................ 150

6.2 Principles of Workflow Re-engineering ............................................................................ 151 6.2.1 Workflow Re-Engineering ............................................................................................................... 151 6.2.2 The Re-Engineering Process ............................................................................................................ 152

6.3 Quality Improvement Principles and Practices ................................................................ 154 6.3.1 Implementing Quality ....................................................................................................................... 155 6.3.2 Quality Assurance and Quality Control ......................................................................................... 155 6.3.3 What Organizations Influence Quality? ......................................................................................... 155


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6.3.4 Quality Improvement Methodologies ............................................................................................ 156 6.3.5 The Seven Basic Tools of Quality ................................................................................................... 158


7 Health Information Technology Systems ................................................................................ 169 7.1 Computer Systems ............................................................................................................. 170

7.1.1 Programming ...................................................................................................................................... 170 7.1.2 Data and Control Structures in Programming .............................................................................. 174 7.1.3 Software Development Lifecycle (SDLC) ..................................................................................... 180 7.1.4 System Integration ............................................................................................................................. 183 7.1.5 Software Quality ................................................................................................................................ 186 7.1.6 Information Systems Design and Analysis .................................................................................... 187

7.2 Architecture ........................................................................................................................ 191 7.2.1 Systems Architecture ......................................................................................................................... 191 7.2.2 Data Warehouse ................................................................................................................................. 192 7.2.3 Data Mart ............................................................................................................................................ 193 7.2.4 Network Architecture ....................................................................................................................... 194 7.2.5 Data and Databases ........................................................................................................................... 195 7.2.6 Software Engineering Architectures ............................................................................................... 199

7.3 Networks ............................................................................................................................ 202 7.3.1 Network Topology ............................................................................................................................ 202 7.3.2 Telecommunications ......................................................................................................................... 205

7.4 Security ............................................................................................................................... 207 7.4.1 The HIPAA Security Rule and Other Government Regulations .............................................. 208 7.4.2 Firewalls .............................................................................................................................................. 211 7.4.3 Virtual Private Networks .................................................................................................................. 211 7.4.4 Encryption .......................................................................................................................................... 212 7.4.5 Security Best Practices ...................................................................................................................... 214 7.4.6 How Hackers Can Access Your Information ............................................................................... 214

7.5 Data .................................................................................................................................... 215 7.5.1 Integrity ............................................................................................................................................... 216 7.5.2 Mapping .............................................................................................................................................. 217 7.5.3 Manipulation ....................................................................................................................................... 218 7.5.4 JOIN Statements ............................................................................................................................... 223 7.5.5 Data Representation and Types ...................................................................................................... 227 7.5.6 Data Warehousing ............................................................................................................................. 229 7.5.7 Data Mining and Knowledge Discovery ........................................................................................ 230


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7.6 Technical Approaches that Enable Data Sharing ............................................................. 234 7.6.1 Non-Technical Approaches ............................................................................................................. 235 7.6.2 Technical Approaches .................................................................................................................. 235 7.6.3 Dealing With Multiple Identifiers ................................................................................................... 240


8 Human Factors Engineering ................................................................................................... 254 8.1 Human Factors .................................................................................................................. 254 8.2 Human Factors Engineering ............................................................................................. 255

8.2.1 Human Limitations, and Methods to Mitigate Them .................................................................. 256 8.3 Human-Computer Interaction .......................................................................................... 257

8.3.1 Predictive Models .............................................................................................................................. 258 8.3.2 Descriptive Models ............................................................................................................................ 259 8.3.3 HCI Theories & Approaches ........................................................................................................... 259 8.3.4 Activity Theory .................................................................................................................................. 259 8.3.5 Human-Centered Design .................................................................................................................. 259 8.3.6 Mental Models .................................................................................................................................... 260 8.3.7 Information Processing Theory ...................................................................................................... 261 8.3.8 Value Sensitive Design ...................................................................................................................... 261 8.3.9 GOMS ................................................................................................................................................. 261 8.3.10 Keystroke Level Modeling ............................................................................................................. 261

8.4 HCI Evaluation .................................................................................................................. 262 8.4.1 Usability Testing ................................................................................................................................ 262

8.5 Interface Design Guidelines and Principles ...................................................................... 263 8.5.1 Nielsen’s Heuristics ........................................................................................................................... 263 8.5.2 Object-Action Interface .................................................................................................................... 264 8.5.3 Human-Interface Guidelines ........................................................................................................... 264 8.5.4 Responsive Web Design ................................................................................................................... 264 8.5.5 AMIA Recommendations for Improving EHR Usability ........................................................... 265

8.6 Usability Engineering ........................................................................................................ 265 8.6.1 Usability & Usability Engineering Standards ................................................................................ 265


9 Health Information Systems and Applications ........................................................................ 270 9.1 Electronic Health Records/Electronic Medical Records ................................................. 270 9.2 CDS/CDSS ........................................................................................................................ 271 9.3 CPOE ................................................................................................................................. 272


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9.4 Radiology Information Systems/PACS ............................................................................. 273 9.5 Laboratory Information System ......................................................................................... 274 9.6 Inventory & Supply Chain Management ........................................................................... 275 9.7 Medication Administration Systems ................................................................................. 275 9.8 Personal Health Record ..................................................................................................... 276 9.9 Other Software ................................................................................................................... 277 9.10 Types of Functions Offered by Health Information Systems ......................................... 277 9.11 Types of Settings Where Systems are Used ..................................................................... 278

9.11.1 Clinical Settings ................................................................................................................................ 278 9.11.2 Non-clinical Settings ....................................................................................................................... 278

9.12 EHR Systems as a Foundational Tool ............................................................................ 279 9.13 Telemedicine ................................................................................................................... 280 9.14 Review Questions ............................................................................................................ 283

10 Clinical Data Standards .......................................................................................................... 285 10.1 Standards Development History and Current Process ................................................... 285

10.1.1 Timeline of Standards Development History ............................................................................. 286 10.1.2 Standards Development Current Process ................................................................................... 286

10.2 Data Standards and Data Sharing ................................................................................... 287 10.2.1 HL7 .................................................................................................................................................... 288

10.3 Transaction Standards ..................................................................................................... 295 10.3.1 HIPAA Transaction Standards ..................................................................................................... 295 10.3.2 Electronic Funds Transfer ............................................................................................................. 296

10.4 Messaging Standards ....................................................................................................... 296 10.4.1 Digital Imaging and Communications in Medicine (DICOM) ................................................ 296 10.4.2 NCPDP SCRIPT ............................................................................................................................. 297 10.4.3 CEN ISO/IEEE 11073 ................................................................................................................. 297

10.5 Nomenclature, Vocabulary, and Terminology ................................................................ 297 10.5.1 Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) ........................... 298 10.5.2 Logical Observation Identifiers Names and Codes (LOINC) ................................................. 299 10.5.3 International Classification of Diseases (ICD) Clinical Modifications (CM) ......................... 300 10.5.4 RxNorm ............................................................................................................................................ 301

10.6 Ontology and Taxonomy ................................................................................................. 302 10.6.1 Taxonomy ......................................................................................................................................... 302 10.6.2 Ontology ........................................................................................................................................... 303 10.6.3 Meta-thesaurus ................................................................................................................................. 303

10.7 Interoperability Standards ............................................................................................... 304 10.7.1 Levels of Interoperability ............................................................................................................... 304


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10.7.2 FHIR – Fast Healthcare Interoperability Resources ................................................................. 305 10.8 Other standards ............................................................................................................... 305 10.9 Review Questions ............................................................................................................ 307 10.10 Suggested Reading ........................................................................................................ 312

11 Information System Lifecycle ................................................................................................ 313 11.1 Governance ...................................................................................................................... 313

11.1.1 Clinical IT Governance .................................................................................................................. 315 11.1.2 Rules and Agreements .................................................................................................................... 316

11.2 The Clinical Information System Lifecycle ..................................................................... 317 11.2.1 Clinical Information Needs Analysis ............................................................................................ 317 11.2.2 The Requirements Specification Document ............................................................................... 319

11.3 Risk Management ............................................................................................................ 321 11.3.1 Planning Risk Management ........................................................................................................... 321 11.3.2 Risk Identification ........................................................................................................................... 321 11.3.3 Qualitative Risk Analysis ................................................................................................................ 322 11.3.4 Quantitative Risk Analysis ............................................................................................................. 323 11.3.5 Risk Response .................................................................................................................................. 323 11.3.6 Controlling Risk ............................................................................................................................... 324 11.3.7 True Cost of Ownership ................................................................................................................ 325

11.4 System Selection .............................................................................................................. 325 11.4.1 Evaluating The Requests for Proposals ....................................................................................... 327 11.4.2 Contracts ........................................................................................................................................... 327

11.5 Clinical Information System Implementation ................................................................. 328 11.5.1 Elements of a System Implementation Plan ............................................................................... 329 11.5.2 User Training ................................................................................................................................... 330 11.5.3 Obtaining Clinician Feedback ....................................................................................................... 331

11.6 Information System Testing Before, During, and After Implementation ...................... 331 11.6.1 Testing Basics ................................................................................................................................... 331 11.6.2 Testing Methods .............................................................................................................................. 332 11.6.3 Testing Levels .................................................................................................................................. 333 11.6.4 Testing Types ................................................................................................................................... 333

11.7 Clinical Information System Maintenance ...................................................................... 334 11.7.1 Data Loss Prevention & Recovery ............................................................................................... 334 11.7.2 Downtime ......................................................................................................................................... 334 11.7.3 Transitioning and Decommissioning ........................................................................................... 335

11.8 Clinical System Evaluation .............................................................................................. 336 11.8.1 The Evaluation Plan ....................................................................................................................... 336


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11.8.2 Outcomes Relevant to Clinical Goals and Quality Measures ................................................... 336 11.8.3 Qualitative and Quantitative Methods of Evaluation ................................................................ 337

11.9 Review Questions ............................................................................................................ 339 11.10 Lifecycle Suggested Reading ........................................................................................ 343

12 Leadership and Managing Change ........................................................................................ 344 12.1 Leadership Models, Processes, and Practices ................................................................. 344

12.1.1 Leadership Process .......................................................................................................................... 347 12.1.2 Leadership Styles ............................................................................................................................. 347 12.1.3 The Dimensions of Effective Leadership ................................................................................... 348 12.1.4 Governance ...................................................................................................................................... 348 12.1.5 Conflict Management ..................................................................................................................... 349 12.1.6 Negotiation ....................................................................................................................................... 352 12.1.7 Collaboration .................................................................................................................................... 353 12.1.8 Motivation ........................................................................................................................................ 353 12.1.9 Decision-Making ............................................................................................................................. 355

12.2 Effective Interdisciplinary Teams ................................................................................... 356 12.2.1 HR Management ............................................................................................................................. 357 12.2.2 Team Productivity and Effectiveness .......................................................................................... 360 12.2.3 Group Management Processes ...................................................................................................... 363 12.2.4 Managing Meetings ......................................................................................................................... 365 12.2.5 Managing Group Deliberations .................................................................................................... 366

12.3 Effective Communications .............................................................................................. 367 12.3.1 Communications Basics ................................................................................................................. 367 12.3.2 Individual & Group Presentations ............................................................................................... 369 12.3.3 One-on-One Communication ....................................................................................................... 370 12.3.4 Effective Writing ............................................................................................................................. 372 12.3.5 Communications Support for Implementation Support ........................................................... 373

12.4 Project Management ........................................................................................................ 373 12.4.1 Basic Principles ................................................................................................................................ 374 12.4.2 Identifying Resources ..................................................................................................................... 377 12.4.3 Resource Allocation ........................................................................................................................ 380 12.4.4 Project Management Tools ............................................................................................................ 381 12.4.5 Informatics Project Challenges ..................................................................................................... 382

12.5 Strategic Planning for Clinical Information Systems ...................................................... 384 12.5.1 Establishing Mission and Objectives ........................................................................................... 384 12.5.2 Assessing the Organization ............................................................................................................ 385 12.5.3 Long-Term and Short-Term Planning ......................................................................................... 387


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12.5.4 Writing the Strategic Plan ............................................................................................................... 389 12.5.5 Evaluating & Implementing the Plan ........................................................................................... 390

12.6 Organizational Finance ................................................................................................... 390 12.6.1 The Financial Plan ........................................................................................................................... 391 12.6.2 Managerial Accounting Principles ................................................................................................ 393

12.7 Change Management ....................................................................................................... 395 12.7.1 How to Assess the Corporate Environment .............................................................................. 396 12.7.2 Change Management Theories ...................................................................................................... 397 12.7.3 Change Management Strategies .................................................................................................... 400 12.7.4 Implementing Effective Change Management ........................................................................... 401 12.7.5 Getting Change to “Stick” or “Refreeze” ................................................................................... 402 12.7.6 Strategies for Systems Adoption ................................................................................................... 403

12.8 Review Questions ............................................................................................................ 405 12.9 Recommended Reading .................................................................................................. 413


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Disclaimer Although the author and publisher have made every effort to ensure that the information in this book was correct at press time, the author and publisher do not assume and hereby disclaim any liability to any party for any loss, damage, or disruption caused by errors or omissions, whether such errors or omissions result from negligence, accident, or any other cause. Except as specifically stated in this book, neither the author or publisher, nor any authors, contributors, or other representatives will be liable for damages arising out of or in connection with the use of this book. This is a comprehensive limitation of liability that applies to all damages of any kind, including (without limitation) compensatory; direct, indirect or consequential damages; loss of data, income or profit; loss of or damage to property and claims of third parties.


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About this Book We’re glad we can join you on your journey towards becoming a board certified clinical informaticist. Our goal is to provide you with a concise presentation of the basic principles of clinical informatics in an easy to understand format. As you prepare for the exam, we hope you use this book in combination with your clinical experience as part of your toolkit. We will cover the major topics in the examination content outline, though we may have reorganized some of it in the interest of flow and clarity. Each section will focus on a “core content” topic. We have also recommend some additional reading at the end of most sections for those who find a topic interesting and would like to dive deeper into the material. The major sections of this book are as follows:

• Exam Details

• Clinical Informatics Overview

• The Health System

• Clinical Decision Making and Care Process Improvement

• Evidence Based Patient Care

• Workflows Analysis, Process Redesign, and Quality Improvement

• Health Information Technology Systems

• Human Factors Engineering

• Health Information Systems Applications

• Clinical Data Standards

• Information System Lifecycle

• Leadership and Managing Change Periodically, we’ll update the content of this book (typically once a year). If you’d like to receive notifications about these updates, please visit informaticspro.com and let us know. This is also the place to find out information regarding access to our companion set of questions to help gauge your strengths and weaknesses. This is an exciting time in the development of this new area of expertise and we hope to provide you with the knowledge it will take to become a pioneer in the field of clinical informatics. If have any comments or suggestions, please let us know at: [email protected]. Happy studying!


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Practice Questions Each chapter in this book has review questions designed to test your understanding of the topics covered. For those interested, additional practice questions, practice exams, and other materials and resources are available on our website at www.informaticspro.com. We would like to note that it is likely that there will be differences between the questions we present and the questions on the exam. Since we cannot know for sure the style of test questions due to the confidentiality agreements, our questions will be written following the National Board of Medical Examiners guide for written test questions for the basic and clinical sciences.


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1. Exam Details

1.1 Topics Covered

The clinical informatics subspecialty board certification exam covers a wide variety of topics ranging from leadership and change management to clinical information system implementation. Within your current studies and experience, it is likely you have touched on many of these topics. It is our goal to bring you up to a level of understanding and knowledge that will allow you to pass your board exam.

Figure 1-1: Composition of the exam

In terms of topic distribution, the test should cover four main areas in the proportions depicted above in figure 1-1. According to ABPM, (the overseer of the exam) the questions should reflect situations potentially faced as a practicing clinical informaticist. In particular, ABPM states:

The distribution of examination questions is weighted in favor of relevance to actual practice; however, candidates who are preparing to represent themselves as competent must recognize they are responsible for knowledge and skills across the breadth of their chosen subspecialty, not just in the preponderant content of their personal day-to-day practice. Examinations do not stress esoteric facts, and they do not require examinees to demonstrate sound understanding. 1

1 The American Board of Preventive Medicine. Study Guide Materials Examinations Content Outline. ABPM website. http://www.theabpm.org/applicationci/ci_studyguide.pdf. Published March 2015.


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The exam should not require you to memorize obscure acronyms or uncommon definitions. Rather, we will attempt to get you to a point where you can take the information presented in this book and apply it to common scenarios you may face in practice.

1.2 Requirements for Certification

At time of publishing, the following are the requirements to receive a certification in the clinical informatics sub-specialty. They consist of:

• A medical school degree

• An ABMS board certification

• A valid medical license

• Completion of one of two following “pathways” • Practice

• Fellowship

The requirements outlined by ABPM include a degree, board certification, licensure and completion of one of two pathways:2 A Degree Meeting one of the Following Criteria:

• A degree from a Liaison Committee on Medical Education accredited school

• A degree from an American Osteopathic Association accredited school

• A degree from an accredited medical school in Canada

• A degree from a medical schools outside the United States and Canada deemed satisfactory to the Board

ABMS Board Certification in one of the Following:

• The American Board of Allergy and Immunology

• The American Board of Anesthesiology

• The American Board of Colon and Rectal Surgery

• The American Board of Dermatology

• The American Board of Emergency Medicine

2 The American Board of Preventive Medicine. The American Board of Preventive Medicine Clinical Informatics Board Certification” www.theabpm.org


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• The American Board of Family Medicine

• The American Board of Internal Medicine

• The American Board of Medical Genetics

• The American Board of Neurological Surgery

• The American Board of Nuclear Medicine

• The American Board of Obstetrics and Gynecology

• The American Board of Ophthalmology

• The American Board of Orthopaedic Surgery

• The American Board of Otolaryngology

• The American Board of Pediatrics

• The American Board of Physical Medicine and Rehabilitation

• The American Board of Plastic Surgery

• The American Board of Preventive Medicine

• The American Board of Psychiatry and Neurology

• The American Board of Radiology

• The American Board of Surgery

• The American Board of Thoracic Surgery

• The American Board of Urology

• The American Board of Pathology*

*Note: Those certified by the American Board of Pathology must apply through ABPath. All others may apply through ABPM.

1.2.1 Licensure

Applicants must posses an unrestricted and currently valid license or licenses to practice medicine in a state, the District of Columbia, commonwealth or territory, or possession of the United States, or in a Province of Canada.

1.2.2 One of the Following “Pathways” to Certif ication

Through 2017, either pathway is acceptable. After 2018, applicants must complete a minimum 24 month clinical informatics fellowship accredited by ACGME.


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1.2.2.1 Pract i ce Pathway

Three years of practice in Clinical Informatics is required. Practice time must be at least 25% of a Full-Time Equivalent (FTE) to be considered. Practice time need not be continuous, however, all practice time must have occurred in the five-year interval immediately preceding application for certification.3

• Practice must consist of broad-based professional activity with significant clinical informatics responsibility.

• Documentation of clinical informatics research and teaching activities may also be submitted for review.

• Verification is required that the equivalent of at least 3 years of an individual's professional time has been devoted to the practice of clinical informatics during the five years prior to application for the examination.

A person or persons who are knowledgeable about the applicant’s practice, such as the Chief of Staff, the applicable department chair, the director of a related clinical informatics training program, or the director of the clinical informatics program in the related institution must complete the verification. Completion of the verification by a partner or practice associate is not acceptable. The verification form will be available at the time of application. For those who completed non-accredited fellowship training of less than 24 months, the fellowship-training curriculum as well as a description of the actual training must also be submitted. The applicant must submit evidence of additional practice to satisfy any additional Practice Pathway requirements.

1.2.2.2 Fel lowship Training Pathway

For those taking the fellowship pathway, completion of a fellowship program of at least 24 months in duration that is acceptable to the ABPM is required. The non-accredited fellowship training curriculum as well as a description of the actual training must be submitted. Training in a non-accredited fellowship program of less than 24 months in duration may be applied toward the practice pathway (see Practice Pathway above). Starting in 2018, only programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME) will be accepted. As of early 2016, programs with an ACGME certified clinical informatics program include:

• Beth Israel Deaconess Medical Center

• Boston Children’s Hospital 3 The American Board of Preventive Medicine. The American Board of Preventive Medicine Clinical Informatics Board Certification www.theabpm.org


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• The Children’s Hospital of Philadelphia

• David Geffen School of Medicine at UCLA and UCLA Health

• Geisinger Health System

• Oregon Health & Science University School of Medicine

• Regenstrief Institute, Inc.

• Stanford School of Medicine

• The University of Arizona College of Medicine – Phoenix

• University of Illinois at Chicago College of Medicine

• Vanderbilt University Department of Biomedical Informatics As clinical informatics grows and matures, expect to see this list expand. In fact, it may have expanded between the time this book was printed and when you’re reading it, so be sure to check out the AMIA website or our website for updates on newly certified programs.

1.3 Exam Day

1.3.1 The Exam Format

The exam is a computer-based exam consisting of 200 equally weighted multiple-choice questions with a four-hour time limit. There are no penalties for guessing or leaving an answer blank. Here is an example of the question format: The IOM core value for efficiency is best exemplified by the following statement:

1. Resources are optimized to allow for the largest number of patients to be seen by a clinician.

2. Human and physical resources are managed in ways that minimize waste and optimize access to appropriate treatment.

3. Goal-directed services are promptly provided in order to restore and sustain the integration of clients and families into the

community.

4. The prevention of patient harm in a timely matter.

Question types may include:

• Clinical vignettes

• Experimental or statistical observations

• Definitions or classifications

• Administrative problems

• Applications of principles or regulations

• Any other scenario that may be seen in practice


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The exam will have no “trick questions”, should not include any obscure acronyms, and will aim to test your knowledge and how it applies to practice. Following basic testmanship, if you don’t know the answer, eliminate the improbably answers and then take your best guess from the remaining possibilities. Do not leave any questions blank, as every question is weighted equally and there are no penalties for incorrect answers. If you’re unsure of a question, you can mark it and come back to it at the end of the exam if time permits. Before the test questions begin, there will be an optional tutorial on how to use the computer based testing system. You can choose to click through it quickly to get to the questions, go through it thoroughly to understand the system, or you can choose to use the time for a “brain dump” before beginning the exam. A tutorial for the computer-based system is available at http://measurementresearch.com/testing/tutorial.shtml.

1.3.2 Registering for the Exam

To be eligible to take the exam, individuals are required to fill out an application and pay a non-refundable application fee. If it is determined you meet the requirements, you will then have to pay an examination fee. Once these two steps are complete, applicants will receive a confirmation letter from which they can

register for the exam – either through Pearson VUE or the ABPM’s registration hotline @ 877-392-3926. Please make sure that you check with ABPM for the latest details, since cancellations or deferrals occurring before the cancellation date will incur an administrative fee. Cancellations occurring after the cancellation date will not receive a refund or deferral.

1.3.3 The Exam Location

Testing is done at Pearson VUE locations across the US. You may choose which one is most convenient for you. Be sure to arrive 30 minutes early for your exam. Late arrivals will forfeit their seat. It is also strongly recommended that you bring several forms of ID with you just in case and your confirmation

letter. Pearson VUE is strict with their identification policy and will not let you take the exam if you can’t prove who you say you are. For the most up-to-date details, please check out the ABPM Clinical Informatics Exam page at http://www.theabpm.org/examinfo-ci.cfm.


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2 Clinical Informatics Overview Clinical Informatics is the application of informatics, clinical knowledge, and technology to continuously improve healthcare systems, services, and outcomes. It seeks ways to:

• Better assess, design, implement, and evaluate clinical information systems for providers, patients, and administrators

• Understand, evaluate, and re-engineer clinical processes so they may improve the quality of healthcare and create efficient and effective workflows

• Lead and manage organizations through times of change—especially through information technology (IT), clinical, regulatory, and health system changes

• Improve the clinical decision making process As depicted below in Figure 2-1, clinical informatics as a discipline resides at the intersection of three major domains: the health system, clinical care, and information & communications technology. Clinical care deals with the clinical care of patients, clinical decision-making, and clinical workflows. The health system deals with managing individual and population health, the regulations and requirements of the healthcare system, health economics and financing, and managing and improving the quality of care. Information and communications technology deals with the computer systems, architecture, networks, and other technical underpinnings of clinical information systems that keep health care systems up and running.

Figure 2-1: Clinical informatics as it relates to other disciplines


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2.1 What is a Clinical Informaticist?

According to the American Medical Informatics Association, a clinical informaticist is someone who

transforms healthcare by “analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve patient care,

and strengthen the clinical-patient relationship.” 4 Essentially, a clinical informaticist is a change agent to help bring information technology to the clinical domain. We’ll cover the common positions held by clinical informaticists in “Informatics as a Career.”

2.2 Informatics History

The recording of healthcare data has been around since Hippocrates first developed the medical record in the fifth century.5 Since then, records have evolved from tablets and paper ledgers to electronic

repositories. However, over the course of health record development, there has never been a “standard” patient record. Configurations, units of measurement, and style of recording have made the conversion from written record to electronic health record one of the greatest challenges in the health information technology industry. We are making significant process towards interoperability in healthcare using technology, standards, best practices, new research, regulations, and informed stakeholders. Fifty years ago, the first research on diagnostic decision-making, “Reasoning Foundations of Medical Diagnosis,” reviewed methods that could be used where risk and uncertainty existed.6 This paper began the conversation on computer-based clinical decision support. Following this, additional papers were published in the mid-80’s that included topics in medical informatics frameworks, functional and architectural considerations for clinical information systems, medical research analysis, and standardizing electrocardiogram analyses from computers.7 In terms of informatics, the use of computer technology in the early 1950s began to influence the field of medicine and the first health informatics organizations were born. The first of which was founded in Germany during 1949, with more and more beginning to appear during the 1960s and 70s across Europe and the United States. The largest and most prominent professional organization from this time is the International Medical Informatics Association (IMIA).

4 Garner, R.M., Overhage, J.M., Steen, E.B., Munger, B.S., Holmes, J.H., Williamson, J.J., Detmer, D.E. (2009). Core content for the subspecialty of clinical informatics. Journal of the American Medical Informatics Association. Vol 16 No 2. DOI 10.1197 5 National Institutes of Health National Center for Research Resources (2006). Electronic health records overview. www.himss.org 6 Ledley, R.S. and Lusted, L.B. Reasoning Foundations of Medical Diagnosis. Science. 130 (1959) 9021. 7 Haux, R. Medical informatics: past, present, future. International journal of Medical Informatics. 79 (2010) 599-610.


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2.2.1 A History of the Clinical Informatics Subspecialty

In 1989, the American Medical Informatics Association (AMIA) was formed as the United States representative to IMIA through the integration and merging of the following informatics organizations:

• American Association for Medical Systems and Informatics

• American College of Medical Informatics

• Symposium on Computer Applications and Medical Care Its mission is to “lead the way in transforming health care through trusted science, education, and the practice of informatics”. In 2005, AMIA began the process to make clinical informatics a recognized subspecialty by the American Board of Preventative Medicine. Below you can see the timeline of the

clinical informatics subspecialty’s development.

Figure 2-2: Timeline for the evolution of the clinical informatics sub-specialty

2.3 Domains of Informatics

As you might expect from a field with the diversity and quantity of influences as medical informatics, the domains and subspecialties associated with clinical informatics are equally varied. Some of the major domains in medical informatics are translational bioinformatics, imaging informatics, clinical informatics and public health informatics. We’ll briefly review each of these domains, though this is just a small sampling of a growing set of domains.

Figure 2-3: Domains of informatics


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2.3.1 Translational bioinformatics

Translational bioinformatics is concerned with the development of methods to optimize the transformation of huge amounts of data, such as those from genetic analyses. This is one example of “big data” and mining of such big data to obtain new knowledge. As you might expect, as we develop methods to store large amounts of data we have to develop corresponding techniques to enable us to analyze this type of data more effectively. This is the realm of translational bioinformatics. Although translational bioinformatics may at some point influence clinical informatics through their results, it’s not precisely clinical informatics.8

2.3.2 Imaging informatics

Imaging informatics, or radiology informatics is concerned with the “efficiency, accuracy, and reliability of radiologic services within the medical enterprise.”9 Picture Archiving and Communication Systems (PACS) and other imaging solutions, combined with EHRs and Health Information Exchanges (HIEs) have allowed the field of imaging informatics to grow into its own subspecialty of diagnostic radiology. Imaging informaticists may seek new ways to process and compress images, integrate images into EHRs, mine data from image databases, enhance images, create vocabularies, ontologies, and more. Radiologists may undergo an imaging informatics fellowship if informatics is a field of interest to them.

2.3.3 Public health informatics

Public health informatics shares some aspects of translational bioinformatics in that it is concerned with the analysis of large sets of data. However, public health informatics’ focus is to promote and support areas of public health. Some of the unique challenges of public health informatics are the integration of large sets of data that come from disparate sources. This is one of the touch points to clinical informatics because the source of much of the public health informatics data comes from clinical systems. We will discover and discuss in subsequent sections the importance of and strategies for the implementation of standardized data, standardized messaging, and standardized transactions.

2.3.4 Clinical informatics

With the many domain of informatics, you can see that clinical informatics is only one facet of a number of healthcare informatics domains. Clinical informatics varies from many of the other informatics domains in that it couples clinical information systems and the data they produce with the way decisions are made, how leadership and management affect change, and how data and information systems can be used to provide better clinical care.

8 AMIA. Translational bioinformatics. www.amia.org 9 Branstetter, B (2007). "Basics of Imaging Informatics". Radiology 243 (3): 656–67. doi:10.1148/radiol.2433060243


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Index A/B Testing, 59 ABPath, 4 Accountable Care Organizations, 16, 164 Accountant, 53 Accreditation, 12 Accreditation Council for Continuing Medical Education,

21 ACID, 14 Action-Object Interface, 61 active listening, 111 Activity theory, 53, 164 Actual Cost, 128 Additional Biases, 81 Administrative controls, 31 Affiliations, 31, 32 Affordable Care Act, 2, 26, 69, 95 Agency for Healthcare Research and Quality, 72, 113, 128,

169 Agendas & Minutes, 103 Agile, 199, 57 alert fatigue, 104, 105, 106, 164 Alerts, reminders, and prompts, 105, 106, 164 Alternate keys, 15 American Medical Informatics Association, 12, 164 American Medical Informatics Association (AMIA), 18 American Osteopathic Association’s Healthcare Facilities

Accreditation Program, 13 Analyzing Literature: critical analysis, 25 Anchoring, 85 ANSI ASC X12, 16 application fee, 8 Arden Syntax, 115, 6, 165 Array, 195 artificial neural networks, 112 Asbru, 116, 165 Assessment, 18 Assurance, 18 attributes, 188, 189, 13, 17, 16, 39, 67 Authoritarian, 74 Autonomy, 29, 165 Availability Bias, 80, 165 Background Questions, 147, 165 backward mapping, 14

Balance Sheet, 54 Basic Tools of Quality, 173 BATNA, 81 Bayes’ Theorem, 89, 90, 165 Beginning of Life, 35 Beneficence/ Nonmaleficence, 29, 165 Best Interest Standard, 30, 165 BHAG, 136 Bias, 24, 153 Bidirectional Data Flow, 26 Bioethics, 35 Biomedical research, 150 BMJ Clinical Evidence, 127 board certification, 1, 2, 21 Bookkeeper, 53 Boolean, 26 Breach Notification Rule, 50 Budgets, 56 business associates, 27, 50 Bylaws, 12, 165 capital budget, 142, 143 Capitation, 59 Care Ethics, 32, 166 Cash Flow Statement, 55 CCD, 5 CCOW, 3 CCR, 10 CDA, 2 CEBM Levels of Evidence, 131 Centralized computing, 5 Certainty Levels, 130 Certificate of Need, 59 Certified Professional in Healthcare Information and

Management Systems, 18 change management, 165, 147 Character, 26 Check sheets, 174 Checklists, 174, 175, 67 Chief Financial Officer, 11, 53 Children’s Health Insurance Program, 7 class, 68, 188, 189 classification trees, 112 Clinical care, 9


446

Clinical decision support, 79, 101, 102, 103, 107, 108, 109, 111, 112, 113, 118, 119, 120, 121, 122, 124, 68, 75, 6, 166

Clinical guidelines, 132, 133, 167 clinical informaticist, 10 clinical informaticists: careers, 15 Clinical Informatics, 9, 167 clinical or medical algorithm, 139, 166 Clinical research, 19, 167 clinical workflow, 108, 116, 155, 158, 162, 39 Clinical workflow analysis, 79 Clinician interviews, 110 Collaboration, 82 Common Data Format, 205 Complex Adaptive Systems, 154 Confirmation Bias, 81, 167 Conflict Management, 77 Conjunction fallacy, 85 Consensus decision-making, 99 Constructive conflict, 77 contingency table, 100, 101 Continuing Medical Education, 21, 168 continuum of care, 13, 16, 69, 168 control chart, 177 Control structures, 192 Controller, 53 Cost Effectiveness, 63, 94 Cost Minimization, 63 Cost Performance Index, 128 Cost Utility, 63 Cost-Benefit, 63 cost-effectiveness, 95 Council of Medical Specialty Societies, 27, 168 CPOE, 60, 69, 75, 77, 66 Credentialing, 18, 13, 168 critical, 125 critical path, 125, 126, 127 Currency of information, 84 D.0, 11 data, 11 Data and Information Flow, 24 Data anonymization, 39, 43 Data architecture, 10 Data at rest, 8 Data Displays, 105

data encapsulation, 188 Data exchange, 36 Data Generalization, 43 Data in motion, 8 Data in use, 8 Data integrity, 12, 13 Data mapping, 12, 14 data mart, 8, 27 data mining, 112, 7, 12, 26, 27, 28, 29, 30, 77 data model, 12, 14, 32, 4 Data Perturbation, 43 Data representation, 12, 25 Data sets, 29 Data Standards, 83 Data structures, 194, 5 Data suppression, 43 Data types, 26 Data warehouse, 7, 26 Data Warehouses, 27 Database Controls, 17 database management system, 6, 11 Data-flow Diagram, 3 data-mining, 112 Death and Dying, 2 Decision analysis, 86 Decision making frameworks, 83 Decision Science, 22, 80, 85 decision tree, 87, 88 Decision-making, 35, 82, 86 Declarative, 186 Decomposition Diagram, 3 Default heuristic, 85 defect, 161, 171, 173 DeGeL, 114, 115 Delphi method, 100 Demographic Shifts, 69 denormalization, 2 Deontology, 31, 171 Diagnosis-Related Group, 59 DICOM, 71 Digital Imaging and Communications in Medicine, 13 Dilution effect, 85 direct elicitation, 93, 171 Discounted Cash Flow, 144 Discounted Cumulative Gain, 147, 171 Disruptor Roles, 97


447

distributed computing architectures, 5 DMADV, 171, 172 DMAIC, 171, 172 DNS, 27 Documentation Templates, 105 Documenting workflows, 156 Domain Integrity, 14 Double, 191 Earned Value, 127 Earned Value Management, 127, 161 Economic Factors, 68 economic issues, 11 Education, 3, 5, 20, 69, 81, 54, 57 effective communications, 104 Effectiveness, 71, 166, 75 Efficiency, 62, 71, 167, 207, 58, 61 Egoism, 32, 172 EHR-S FM, 8 Electronic Health Records, 18, 2, 66, 75 elements, 16 Encryption, 29, 6, 8, 43 Enterprise Service Bus, 206 environmental scan, 133 EON, 116, 117 Equity, 72, 167 Equivalent Annual Annuity, 145 Errors, 58 Estimate At Completion, 128 Estimate To Complete, 128 Ethical decision-making, 34 ethical questions, 34, 119 Ethical theories, 31 Ethics, 26 Evaluating Guidelines, 139 evaluation, 76, 78, 86, 91, 109, 118, 186, 207, 47, 57, 64, 30,

37, 64, 65, 66, 67, 174, 182 Evidence Based Medicine, 22, 25, 69, 125, 127, 147, 148,

172 Evidence Based Practice, 125 examination fee, 8 Expert Determination, 40 Expert Review, 59 Explanatory theories, 53, 172 extract-transform-load, 7

Fall-out, 146, 172 Fat Clients, 6 FDA, 52, 119, 27 feedback, 89, 90, 91, 126, 158 fee-for-service, 20, 10, 40, 58 FHIR, 24, 26 Fidelity, 30, 173 fields, 65, 66, 185, 188, 17, 43, 63, 191 Finance, 11, 53 Financial accounting, 54, 146 financial plan, 141 Firewalls, 29, 4, 5 Fishbone diagrams, 173 Fitt’s law, 51, 52, 173 Five Rights Model of CDS, 102 Flat File Database, 12 Float, 26 F-measure, 147, 173 Food and Drug Administration Safety and Innovation Act,

52 Foreground Questions, 148, 173 Forward mapping, 14 Foundational, 33, 78 FTC, 28 Functional, 22, 92, 185, 186, 8, 40 Gantt chart, 126 Gellish, 36 GEM, 114, 115 Generative theories, 53, 174 GEODE-CM, 116, 174 Germ theory, 18, 174 GLIF, 116, 174 GOMS, 56, 57, 174 Governance, 75, 77, 174 GRADE system, 131 grading system, 128 Group Maintenance Roles, 97 Group Task Roles, 96 Guiard’s Model, 53, 174 GuideLines Into Decision Support, 111, 112 Harman’s Ethical Challenges, 34 HashMap, 196 HCI Models, 50 Health Information and Management Systems Society, 18


448

Health information systems, 182, 76, 77 Health Maintenance, 9, 22 Health Maintenance Organizations, 9 health system, 9 Healthcare Spending, 66 healthcare system, 6 Heat Mapping, 59 Herzberg’s Two-factor Theory, 84 heuristic decision making, 84 Hick’s law, 52, 175 Hierarchal Database, 12 High-level programming languages, 185 HIMSS, 18, 33, 10, 25 HIPAA, 2, 22, 26, 27, 40, 41, 50, 69, 77, 29, 30, 31, 3, 4, 40,

41, 75, 76, 11, 27, 35, 175 Hippocratic Oath, 28 Hiring, 89 Histograms, 179 History, 11 HITECH, 2, 22, 26, 27, 69, 169 HL7, 84, 87, 3, 4, 5, 9, 10, 25, 26, 29 HL7 International, 87 Horizontal Integration, 206 HR Management, 88 HTTP, 28 Human Factors, xiv, 46, 27, 65 human right, 29 Human-Computer Interaction, 46, 175 Human-Interface Guidelines, 61, 176 ICD, 59, 15, 17, 18, 20 ID set, 38 Identifying Critical Errors, 209 Imaging informatics, 14, 176 Imperative, 185 Income Statement, 54 Independent Practice Associations, 9, 176 indirect assessment, 93, 176 influence diagram, 86, 87, 176 Info Buttons, 105 Informatics Literature: peer review, 24; sources of, 23 Information and communications Information technology,

9 Information processing theory, 56 Information retrieval, 140, 176 Information Retrieval Models, 145

Inheritance, 189 Institute of Medicine, 70, 78 Integer, 191, 26 Integration, 20, 109, 171, 184, 202, 205, 206, 34, 72, 60,

176, 188, 191 Integrity, 75 interchange format, 36 Interdisciplinary Teams, 87 Interest Groups, 16 interface, 51, 139, 189, 203, 6, 10, 52, 60, 61, 62, 63, 3, 4,

27, 60, 176, 186 Interfacing, 34, 35 internal controls, 55 Internal Rate of Return, 144 International Clinical Informatics Practices, 25 International Medical Informatics Association, 12, 18 International Organization for Standardization, 17, 85 Interoperability, 19, 30, 33, 10, 24, 25, 26 Inventory & Supply Chain Management, 73 Investigators, 153 IP Address, 27 ISO, 85 ISO 9241, 63 ISO/TR 16982:2002, 64 IT architecture, 4 IT security, 29 JOIN statement, 22, 23 Joint Commission on Accreditation of Healthcare

Organizations, 3, 12, 177 JSON, 36 Justice, 31, 177 Key Performance Indicators, 139 Keys & Relationships, 15 Keystroke Level Modeling, 57, 178 Knowledge Acquisition, 111, 113 Knowledge Generation, 111, 112 Knowledge Management and Maintenance, 111, 117 Knowledge Management Systems, 113 Knowledge Modeling, 111, 113 Knowledge Representation, 111, 115, 117 Knowledge representation models, 115, 178 Knowledge-based CDSS, 102, 178 Kotter, 156


449

Laboratory Information System, 72 Laissez-faire, 74 Leadership, 70 Leadership Process, 72 Leadership Styles, 73 Lean, 172 Learnability, 57 Legal and Regulatory Issues, 2 levels of evidence pyramid, 149 Lewin’s Change Process, 155 Licensing, 13, 178 Likelihood ratios, 99, 178 List, 195 Local Area Networks, 28 Log analysis, 110 Logic, 115, 184, 186, 19, 6 Logical Integrity, 13 Logical schema, 211 Logical topology, 22 LOINC, 84, 15, 17, 18, 23 loop, 192 Low-level programming languages, 184 machine learning, 102, 112, 27, 30, 170, 180 Maintainability, 188, 208 Maintenance, 23, 110, 118, 61 Managerial accounting, 53, 147 Managing Expectations, 129 Marginal Cost, 62 Markov decision process, 83 Maslow’s Hierarchy of Needs, 84 MBTA, 116, 117 Meaningful Use, 2, 26, 27, 28, 29, 75, 120, 169, 29, 3, 68,

29, 53, 66 Medicaid, 7, 8, 40 Medical Decision Making, 23, 82 Medicare, 7, 8, 9, 16, 27, 28, 40, 51, 59, 74, 169, 29, 12;

Part A, 8; Part B, 8; Part C, 8 Memorability, 58 Mental models, 55, 179 Messaging Standards, 84 Meta-Analyses, 126 Meta-Research Innovation Center at Stanford, 127 Meta-thesaurus, 24 Metcalfe’s law, 22, 26

methods, 11, 13, 24, 25, 27, 52, 53, 58, 93, 109, 115, 122, 126, 130, 137, 157, 158, 172, 185, 188, 189, 198, 203, 205, 2, 27, 37, 39, 40, 41, 56, 58, 59, 64, 55, 57, 66, 67, 176

miasma theory, 17, 180 MLM, 6 monopsony, 11, 180 Motivation, 83 Multi-directional Data Flow, 26 Narcissistic, 74 National Institute for Health and Care Excellence, 127 negative likelihood ratio, 99, 180 Negative Predictive Value, 98, 100, 180 Negotiation, 80 Net Present Value, 143 Network architecture, 4, 9 Networks, 22 Nielsen, 57, 58, 59, 60 Nomenclature, 84, 14, 15 nominal group technique, 98 Non-knowledge based CDSS, 102, 180 normal forms, 16 Normalization, 22, 2, 16 Norms, 95 N-Tier, 18 Object Oriented Database Management System, 12 Object-Action Interface, 61, 181 Objectives, 131, 132, 139 Object-Oriented, 185, 187 Object-Relational Database Management System, 12 Objects, 187, 188 Occupational health, 23, 181 Office of the National Coordinator, 27, 169 Omission Bias, 81, 181 Ontology, 22, 114, 15, 21, 22 operating budget, 142 Opportunity Cost, 62 Order Sets, 105 Organizational Behavior, 149 organizational chart, 11 Organizational culture, 148 Organizational Structure, 11 ORYX, 75 OSI Network Model, 22, 9


450

Outcome Bias, 80, 182 package, 105, 190 PACS, 14, 25, 26, 202, 71, 72, 75 Pareto charts, 176 Participative, 74 partnerships, 18, 31 Pathway, 5 Pathways, 4 Patient Centeredness, 71, 167 Patient engagement, 20 Patient preference assessments, 92, 182 Patient preferences, 91, 182 Patient Protection and Affordable Care Act, 2, 39 Patient Safety, 71, 73, 166, 181 Payback Period, 144 performance management, 75 performance reviews, 90 Personal health, 21 Personal Health Information, 22, 26, 41, 30, 40, 61, 171,

182 Personal Health Record, 22, 74, 183 personal identifiers, 38 Physical controls, 2 Physical Integrity, 13 Physical topology, 22 physician adoption, 20 Physician Quality Reporting System, 51, 74 PICO method, 147, 148 Picture archiving and communication systems, 14 Planned Value, 128 Policy Development, 18 POP3/IMAP, 28 Population Health: determinants, 5 populations, 96, 122, 123, 130 positive likelihood ratio, 99, 183 Positive Predictive Value, 98, 100, 183 post-test probability, 89, 99, 183 PPACA, 2 PQRS, 51, 52, 74 Precede-Proceed, 151, 153 Precision, 146, 147, 165, 183 Predictive Models, 51 Predictive theories, 53 preemption analysis, 4 Preference Assessment, 91

Preferred Provider Organizations, 9, 184 Pre-test probability, 89, 184 primary key, 15, 16, 17, 13, 14, 19 Privacy Rule, 41 private health insurance, 9 PROACTIVE Framework, 83 Probability theory, 86, 88 process modeling, 2 Professional Certifications, 18 Professional development, 92, 184 Professional Organizations, 18 Profitability Index, 145 PROforma, 117, 184 Programming, 22, 184, 185, 187, 190 programming languages, 184, 185, 12 Programming paradigms, 185 Project Charter, 119 Project Management Plan, 119, 185 Project Management Professional, 19 project manager, 114 Project Scope Statement, 119 Prospective Payment System, 59 Prototyping, 200 Public Health, 23, 6, 17, 18, 76, 185 Public health care, 7 Public health informatics, 14, 185 PubMed, 107, 127 quality, 9, 2, 3, 6, 16, 19, 24, 28, 29, 39, 51, 58, 60, 70, 72,

74, 75, 76, 77, 79, 80, 95, 110, 114, 120, 121, 125, 129, 130, 161, 166, 167, 168, 169, 170, 171, 173, 207, 208, 209, 16, 34, 67, 69, 83, 43, 45, 64, 65, 182, 187

Quality Improvement, xiv, 70, 155, 166, 170, 40 Quality Indicators, 72, 73 Quality of Life, 2 Quality-adjusted Life Years (QALYs), 92 query, 144, 146, 16, 17, 18, 21, 22, 24, 185, 186 quivalence, 15 radiology informatics, 14, 176 Rating Scale, 94 RDF, 37 Recall, 146, 61, 185 re-engineering process, 163 Reference Information Model, 3, 9, 29 Registering, 7


451

Regulation, 34, 68 Relational systems, 6 relations, 159, 16 Reliability, 24, 207 Remote Monitoring, 81 Remote Testing, 59 Reporting, 24 Representativeness, 85 Requirements for Certification: requirements, 2 Resource allocation, 124 Resource Scarcity, 62 Resource-Based Relative Value Scale, 59 Resource-constrained projects, 126 Responsive web design, 62, 186 revenue cycle management, 60, 61 Rights, 31, 186 risk management, 76, 77, 32, 42, 177 Risk Preference, 92 Robert’s Rules of Order, 104 ROC curve, 97, 186 Safe Harbor, 41 SAGE, 117 Satisfaction, 58 SBAR, 110 Scatter diagrams, 178 Schedule Performance Index, 128 Scope creep, 128 SCRIPT, 84, 13 Section 508, 64 Security, 22, 28, 41, 208, 17, 29, 30, 3, 4, 8, 9, 38, 42, 25,

54, 60 Security Rule, 41, 30, 175 Semantic, 22, 33, 24 sensitivity, 96, 97, 100 Size, 208 slack, 125, 126, 127 SNOMED, 84, 15, 17, 18, 22, 23 Social influence, 153 software development lifecycle, 197 software development methodology, 198 Software Quality, 184, 206 source, 14 specificity, 96, 97, 99, 100, 19, 66 Spiral, 200 SPL, 5

SQL, 12, 15, 16, 17, 18, 23, 24, 37, 44 SSL/TLS, 28 standard, 83 standard gamble, 93 Standards, xiv, 22, 34, 3, 18, 54, 109, 115, 15, 60, 63, 83,

84, 85, 87, 5, 10, 11, 13, 15, 24, 25, 27, 29 Star Integration, 205 statistical analysis, 96, 112 STICC, 111 Stored Procedures, 15 strategic plan, 76, 131, 132, 133, 139, 140, 141 Stratified sampling, 180 String, 191, 195, 196, 26 Structural, 33 Study Methods, 152 Subcultures, 149 Supply-Demand, 62 Switch/Case statement, 193 SWOT, 133, 134, 135, 136, 139, 189 Syntax, 115, 184, 197 Systematic reviews, 126 Systems architecture, 4 Systems integration, 202 target, 14 Task-Oriented, 74 Taxonomy, 22, 21, 23 TCP, 27 Technical controls, 31 Telecommunication, 26, 87 telemedicine, 79, 80, 81, 82 terminologies, 84, 9, 14, 26 Test Characteristics, 96 Testing, 8, 110, 58, 59, 54, 56, 57, 58, 59, 60, 61, 67, 171 The Cochrane Collaboration, 127 The Sunshine Act, 40 thin client, 6 third-party payers, 58 Time Trade-Off, 94 Time-constrained projects, 125 Timeliness, 71, 167 topic distribution, 1 Total Quality Management, 170 Toxic, 74 Transaction Standards, 84, 11 Translational bioinformatics, 13, 190


452

Treasurer, 53 TRICARE, 7 triple constraint, 115 true negative, 98, 99, 180, 188 true positive, 98, 99, 183, 187 Tuckman, 93 tuple, 16, 17 ubiquitous care, 21 UDP, 28 UMLS, 84, 23 Unbundled Fee-for-Service, 59 Unidirectional Data Flow, 25 United States Preventive Service Task Force, 130 United States Preventive Services Task Force, 128 University of Oxford Centre for Evidence-Based

Medicine, 127 US NIH Clinical Trials, 127 Usability, 19 Usability engineering, 47, 63, 191 usability study, 58 Usability testing, 58, 190 user resistance, 107 user-centered design, 54, 191 Usual, Customary, and Reasonable Costs, 59 Utilitarianism, 32, 191

Utilization management, 76 Validity, 24 Value Sensitive Design, 56, 191 variable, 152, 190, 191, 192, 194, 195, 26 Variable types, 191 Veracity, 31, 191 Vertical Integration, 205 Virtual Private Networks, 29, 5 Virtue Ethics, 31, 191 Visceral Bias, 81, 191 Vision, 75 vocabularies, 109, 84, 24, 25, 26 Walkthroughs, 110 waterfall methodology, 198 Wide Area Networks, 28, 29 Work Breakdown Structure, 119 Workflow analysis, 160 workflow diagram, 158, 159 Workflow Integration, 108 workflow re-engineering, 160, 162, 166 X12, 11 XML, 114, 16, 36, 37, 2, 5, 10, 166

www.informaticspro.com

The Future of Medicine Isn’t in the Exam Room

Clinical Informatics Board Review: Pass the Exam The First Time provides a comprehensive review of the clinical informatics concepts you need to know to pass your subspecialty board examination. Inside you’ll find comprehensive content, straight-to-the-point ex-planations, easy to understand graphics, practice questions, and sug-gested reading for further exploration.

IT’S IN INFORMATICS.

About the AuthorsRocky Reston, MD, PhD is board certified in clinical informatics and anesthesiology with a PhD in electrical engineering. He has served at multiple levels of the healthcare system, from staff physician, depart-ment chair, program director, and C-level executive.

Corinn Pope, MS, PMP is a project manager and web developer. She has managed multiple large-scale health IT projects and developed websites and applications for enterprises and small businesses.

Clinical Informatics Board Review

3155347809869

ISBN 978098631553490000 >

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