Vital Signs

A picture archiving and communication system (PACS) stores, retrieves, displays, and shares medical images such as x-rays, CT scans, MRIs, and ultrasounds. This post explains how PACS works with DICOM, RIS, VNAs, and the EHR, where imaging workflow breaks down, and how it shows up at the bedside.

LOINC gives every lab test and clinical observation a universal code, so a glucose result or a heart rate means the same thing in every system. This post explains how LOINC codes are built, how LOINC differs from SNOMED CT and CPT, where it is required, and why nursing documentation depends on it.

Health information exchange is the electronic movement of clinical information between organizations in a way that keeps its meaning. This post explains the three forms of HIE, how HIEs relate to TEFCA and interoperability, what makes exchange useful, and how it shows up at the bedside.

E-prescribing sends prescriptions straight from the prescriber’s system to the pharmacy. This post explains how e-prescribing differs from CPOE, the NCPDP SCRIPT transactions behind it, the federal requirements for electronic prescribing of controlled substances, and the refill and pharmacy work nurses still manage.

C-CDA is the document standard behind most patient summaries exchanged between U.S. healthcare organizations. This post explains how C-CDA relates to CDA, the CCD, USCDI, and FHIR, which document types it defines, and why nurses meet C-CDA documents at nearly every transition of care.

ADT messages announce every admission, discharge, transfer, and registration to the systems that need to know. This post explains the HL7 v2 events behind ADT, why nearly every hospital system depends on them, how CMS uses ADT for event notifications, and how ADT shapes nursing workflow.

Value-based care pays providers for health outcomes rather than for the number of services they deliver. This post explains how VBC differs from fee-for-service, the spectrum of value-based payment models, the federal programs that drive it, and why it depends on good data and good nursing.

TEFCA is the national framework that connects health information networks into a single network of networks. This post explains the Trusted Exchange Framework, the Common Agreement, QHINs, and the exchange purposes TEFCA supports, and why it matters at transitions of care.

Ransomware locks the systems hospitals depend on and holds them hostage. This post explains how attacks unfold, why HHS presumes a HIPAA breach when ransomware encrypts ePHI, what the Change Healthcare attack revealed, and how nurses keep care safe when the EHR goes dark.

Machine learning is the part of artificial intelligence that learns patterns from data instead of following hand-written rules. This post explains the main types of machine learning, why models must be validated locally, what can go wrong, and why nursing judgment remains the safety layer.

HIPAA began as a 1996 law about keeping health insurance when changing jobs. Its administrative simplification title became the foundation of healthcare privacy, security, and electronic transactions. This post explains the structure of HIPAA, its major rules, how it is enforced, and what it means at the bedside.

EMRAM is HIMSS’s eight-stage model for measuring how fully a hospital uses its electronic medical record. This post explains the stages from 0 to 7, how EMRAM differs from ONC certification, the rest of the HIMSS maturity model family, and what nurses demonstrate when a hospital is validated.

Bar code medication administration is the last electronic check before a medication reaches the patient. This post explains what BCMA verifies, what the evidence shows, why workarounds happen, and why BCMA only works as part of a closed medication loop.

Alert fatigue happens when so many low-value warnings fire that clinicians start ignoring the important ones. This post explains alert fatigue and alarm fatigue, the override evidence, why nurses carry so much of the burden, and the governance practices that make alerts worth reading again.

USCDI is the federal list of health data that certified systems must be able to exchange. This post explains data classes and elements, how USCDI versions advance, how it replaced the Common Clinical Data Set, and how it relates to US Core, C-CDA, and TEFCA.

SNOMED CT is the clinical terminology that lets computers agree on what a diagnosis, finding, or procedure means. This post explains how SNOMED CT works, how it differs from ICD-10-CM, LOINC, and RxNorm, and why coded clinical data starts with the clinicians who document it.

The patient portal is now how most Americans see their own health records. This post explains what portals do, how they differ from personal health records, how the 21st Century Cures Act changed the release of results and notes, and why so much portal work lands on nurses.

Nursing informatics is a recognized nursing specialty, not an IT job that happens to hire nurses. This post explains the data-information-knowledge-wisdom framework at its core, the roles from super user to CNIO, how certification works, and why nursing judgment belongs in every EHR design decision.

FHIR is the HL7 standard that brought modern web APIs to healthcare data, and federal rules now require it. This post explains FHIR resources, how FHIR differs from HL7 v2, C-CDA, and USCDI, why SMART on FHIR matters, and where nurses already meet FHIR without knowing it.

The electronic health record is the system every clinician works inside, but it is more than a digital chart. This post explains what makes a record an EHR rather than an EMR, the eight core EHR functions, what near-universal adoption did and did not fix, and what the EHR means for nurses.