Vital Signs

Big data refers to data sets so large, varied, and fast-moving that traditional tools struggle to store and analyze them. This post explains the volume, variety, and velocity of health data, how organizations use big data for research, operations, and AI, why quality and governance matter more than size, and how nurses contribute to the data.

Arden Syntax is an HL7 standard language for writing clinical decision support rules, called medical logic modules, in a form computers can execute and institutions can share. This post explains how medical logic modules work, why sharing rules proved difficult, and how newer standards such as Clinical Quality Language and CDS Hooks continue the effort.

View, Download, and Transmit (VDT) was a Meaningful Use Stage 2 measure requiring that patients be able to view their health information online, download it, and send it to a third party. This post explains what each part meant, how VDT shaped patient portals, and how today’s API, Promoting Interoperability, and information blocking rules build on it.

A terminology is a system of words or concepts used to name things in a particular field. In health IT, clinical terminologies give computers a shared, coded vocabulary so data keeps its meaning across systems. This post explains how terminologies differ from classifications and code sets, the major U.S. terminologies, how mapping works, and why it matters at the bedside.

Quality improvement (QI) is a systematic, formal approach to analyzing performance and making changes that improve it. This post explains the Model for Improvement and PDSA cycles, related methods such as Lean and Six Sigma, what research says about how PDSA is applied, how health IT and data support QI, and why nurses lead so much improvement work.

A laboratory information system (LIS) manages the workflow of the clinical laboratory, from receiving orders and labeling specimens to interfacing with analyzers and reporting verified results. This post explains LIS functions, how results reach the EHR, the regulatory and standards context, and why specimen collection and labeling at the bedside are critical links in the chain.

Integrating the Healthcare Enterprise (IHE) is an initiative of healthcare professionals and industry that improves how health IT systems share information by specifying how established standards such as HL7 and DICOM should be used together. This post explains IHE profiles, technical frameworks, Connectathons, key profiles for exchange and imaging, and why IHE matters to clinicians.

Electronic clinical quality measures (eCQMs) use data from EHRs and other health IT to measure the quality of care. This post explains how eCQMs are specified and calculated, which CMS programs use them, how they compare with chart-abstracted measures, the move toward digital quality measures, and why structured nursing and provider documentation determines results.

Clinical informatics is the discipline that applies information science and technology to improve how clinicians deliver care. This post explains what the field covers, how it relates to nursing and health informatics, what clinical informaticists do day to day, the certification paths for physicians and nurses, and why the field matters to patient safety.

The Argonaut Project is a private-sector initiative that brought EHR vendors and health systems together to speed adoption of FHIR-based APIs. This post explains why it formed, what it produced, how its work led to US Core and today’s patient access APIs, and how the HL7 FHIR Accelerator model carries the approach forward.

In cybersecurity, a vulnerability is a weakness in a system, process, or control that a threat could exploit. This post explains how vulnerabilities relate to threats and risk, how CVE identifiers and CVSS scores help organizations prioritize, why patching is hard in hospitals, and how compensating controls protect devices that cannot be updated.

Secondary data use is the use of health data for purposes other than the reason it was originally collected, such as research, quality improvement, public health, analytics, and AI. This post explains the main forms of secondary use, the privacy and governance frameworks that apply, why data quality limits what reuse can show, and how nurses contribute.

A plan of care is a documented plan, based on assessment, that identifies a patient’s needs, sets goals, describes the interventions to meet them, and tracks progress. This post explains the parts of a care plan, the CMS requirement for nursing care plans, how standardized terminologies support electronic care planning, and how to keep care plans meaningful.

The minimum necessary standard is the HIPAA Privacy Rule principle that covered entities should limit uses, disclosures, and requests of protected health information to the minimum needed for the purpose. This post explains what the standard requires, where it does not apply, how role-based access supports it, and how nurses apply it in daily practice.

The International Classification of Diseases (ICD), published by the World Health Organization, is the global standard for classifying diseases and health conditions for statistics, epidemiology, and payment. This post explains ICD-10-CM and ICD-10-PCS in the United States, what ICD-11 changes, how ICD differs from clinical terminologies like SNOMED CT, and why documentation drives coding.

A diagnosis related group (DRG) is a category that groups hospital stays with similar diagnoses, treatments, and resource use so that a hospital receives a set payment for each case. This post explains how Medicare’s MS-DRGs work, what drives a case into a group, how case mix and relative weights affect payment, and why accurate clinical documentation matters.

The cloud refers to computing services such as servers, storage, and applications delivered over the internet instead of from an organization’s own data center. This post explains NIST’s definition of cloud computing, the service and deployment models, what HIPAA requires of cloud providers, the shared responsibility model, and what cloud systems mean for clinicians.

The accounting of disclosures is a HIPAA right that lets individuals request a list of certain disclosures of their protected health information made by a covered entity during the previous six years. This post explains what the accounting includes and excludes, how it differs from an audit trail, how organizations track disclosures, and what nurses should know.

A use case is a structured description of how a user interacts with a system to achieve a goal, including the normal path and the exceptions. This post explains the parts of a use case, how use cases drive requirements, design, and user acceptance testing, how they compare with user stories, and why clinicians should help write them.

Train the trainer is a model in which experts prepare instructors, often experienced staff, to deliver training to others, multiplying the reach of a small education team. This post explains how the model works in EHR implementations, the roles of credentialed trainers and super users, what research shows about effectiveness, and how nurses contribute.