Vital Signs

The Certified Health IT Product List, or CHPL, is the authoritative listing of health information technology tested and certified under the ONC Health IT Certification Program. This post explains who tests and certifies products, what the HTI-5 final rule changed, how buyers and CMS programs use the list, and why certification does not guarantee a safe or usable fit.

An adverse drug reaction is an unwanted response to a therapeutic drug. This post explains how ADRs differ from adverse drug events, how voluntary and mandatory FDA reporting works, what a scoping review found about barriers to reporting, how allergy and reaction documentation in the EHR supports safety, and the nurse’s role in recognizing and reporting reactions.

The Universal Medical Device Nomenclature System, or UMDNS, is a standard naming system for medical devices that supports identifying, filing, retrieving, and exchanging data about equipment. This post explains how device nomenclatures work, how UMDNS relates to GMDN and the Unique Device Identifier, uses in inventory, recalls, and procurement, and what nurses should know.

A security administrator is a trained member of the data system management team who manages, monitors, and administers security over one or more networks and helps create a confidentiality-conscious working environment. This post explains the role, how it differs from the HIPAA-required security official, typical duties, safeguards for privileged accounts, and how nurses work with security administrators.

In security, penetration means an intruder gains or attempts to gain unauthorized access to a system or resource. Penetration testing is the authorized practice of simulating that attack to find weaknesses first. This post explains the difference between penetration, penetration testing, vulnerability scanning, and risk analysis, proposed HIPAA requirements, and safety cautions in clinical environments.

Master data management is the practice of linking an organization’s critical data to a single trusted master record that serves as a common reference across systems. This post explains patient, provider, location, and item master data, the role of governance and data quality, how MDM relates to the master patient index, and why MDM can also mean mobile device management.

Identity proofing is the process of collecting and checking enough evidence to establish who a person is before issuing credentials or granting access. This post explains how proofing differs from authentication, the NIST identity assurance levels, where it appears in EPCS, patient portals, and workforce onboarding, and what nurses should know.

EPCS is the electronic prescribing of controlled substances, made possible by DEA rules that require identity proofing, two-factor authentication, and certified software. This post explains how EPCS works, the CMS Medicare Part D requirement, research on adoption and opioid prescribing, and the roles nurses and informaticists play.

The CIA triad is a model for guiding information security policy built on three goals: confidentiality, integrity, and availability. This post explains each goal, how the HIPAA Security Rule requires protecting all three for electronic protected health information, healthcare examples of each, how the goals sometimes conflict, and what nurses do every day to uphold them.

An addendum is new documentation that adds information to an original entry. It should be timely, dated, attributed, and explain why the information was added. This post explains how addenda differ from corrections, late entries, and patient-requested amendments, what CMS recordkeeping principles require, how EHR audit trails support them, and what nurses should do.

Wi-Fi Protected Access is the family of security protocols that protect wireless networks, created to replace the weak Wired Equivalent Privacy standard. This post explains WPA, WPA2, and WPA3, personal versus enterprise modes, the risks of legacy medical devices, NIST guidance for wireless networks, and what nurses and informaticists should know.

Scalability is the ability of a system to maintain the required quality of service as load increases. This post explains vertical and horizontal scaling, cloud elasticity, capacity planning and load testing, common healthcare peak-load scenarios, research that benchmarks scalability, and what slow systems mean for nurses at the bedside.

A problem-oriented medical record organizes health information around a list of the patient’s problems, so notes, orders, and results link to the problem they address. This post covers Lawrence Weed’s design, SOAP notes, the role of the EHR problem list, research on problem list accuracy and completeness, and what nurses and informaticists can do.

Knowledge management is the practice of creating, sharing, using, and managing an organization’s knowledge and information. This post explains tacit and explicit knowledge, how knowledge management supports clinical decision support content, training, and learning health systems, research on nurses and knowledge management, and practical roles for nurses and informaticists.

An incident is an event with the capacity to cause loss or disrupt operations if it is not managed. In health care the word covers patient safety events, security incidents, and operational disruptions. This post explains how HIPAA and NIST frame security incident response, how patient safety event reporting works and where it falls short, and the nurse’s role.

An encounter is an interaction between a patient and a practitioner responsible for assessing or treating the patient. In health IT it is the record unit that anchors clinical documentation, orders, billing, and quality data. This post explains encounter types, how registration creates encounters, common errors, and what nurses should know.

A clinical data repository is a structured, centralized store of patient-specific clinical data collected from many applications. This post explains how a CDR differs from an EHR and a data warehouse, the role of terminology and FHIR, governance and data quality, research use, and what nurses should know about the data they create.

Administrative code sets describe business circumstances in health care transactions rather than diagnoses or procedures. This post explains how HIPAA treats code sets, how administrative codes such as place of service, provider taxonomy, discharge status, and remittance codes differ from medical data code sets, and why nurses and informaticists encounter them.

A vendor is a company that provides products or services. In healthcare IT, vendors supply EHRs, devices, cloud services, and support. This post explains what vendors do, what research says about EHR vendor performance, contract and transparency issues, third-party security risk, and how nurses and informaticists work with vendors during implementation.

System integration is the work of assembling separate hardware, software, and communication elements so they function together for an intended purpose. This post explains integration approaches, the role of interface engines, standards, and APIs, testing and safety risks, the single-vendor versus best-of-breed tradeoff, and what integration means for nurses at the bedside.