Nursing informatics theories, law and ethics

A researcher receives a data set with admission dates and five-digit ZIP codes but no names or medical record numbers. Under HIPAA, this data set is:

1. a limited data set requiring a data use agreement.
   Full dates and five-digit ZIP codes are allowed in a limited data set once direct identifiers are removed, and the recipient must sign a data use agreement.
2. de-identified data under the Safe Harbor method.
   Safe Harbor requires removing all date elements except the year and truncating ZIP codes to three digits, so this set does not qualify; that is the usual trap.
3. identifiable PHI requiring each patient's authorization.
   The data are still PHI, but a limited data set used for research under a data use agreement does not need individual authorizations.
4. anonymized data that falls outside HIPAA entirely.
   Removing names and record numbers is not enough to leave HIPAA; dates and full ZIP codes keep the data as PHI.

A research extract replaces each medical record number with a random study code, and the privacy office keeps the key linking codes to patients. This technique is:

1. hashing.
   Hashing runs a value through a one-way function; it is not a random code with a lookup key, and an unsalted hash of a record number can even be re-derived.
2. encryption.
   Encryption scrambles the whole content so it is unreadable without a decryption key; the extract here stays readable and only the identifier is replaced.
3. data aggregation.
   Aggregation combines records into group totals such as counts per unit, so individual rows and codes no longer exist.
4. pseudonymization.
   Pseudonymization swaps direct identifiers for a code while a separately held key allows authorized re-linking, which is what the privacy office's key provides.

A parent requests proxy access to a 15-year-old's patient portal account. Which design best protects the adolescent?

1. Give the parent full access until age 18
   Unrestricted parental access exposes care that state law lets adolescents receive confidentially and discourages teens from seeking it.
2. Limit the parent's view to non-confidential information
   Adolescent proxy access is typically designed to show parents routine information while shielding care the teen may consent to alone, such as sexual or mental health services, under state minor-consent laws.
3. Give the teen and parent one shared login
   A shared login removes any separation of confidential content and defeats auditing of who viewed what.
4. Deny the parent any portal access at all
   Blocking parents entirely overcorrects; parents usually still have a right to non-confidential information about a minor's care.

Which project situation is best suited to a waterfall approach?

1. The team plans to release features in two-week increments
   Two-week releases describe Agile sprints; waterfall delivers the whole system at the end.
2. Clinical priorities are expected to shift during the build
   Shifting priorities are the reason to choose Agile, which reprioritizes the backlog every iteration; waterfall handles change poorly.
3. Users can describe needs only after seeing working screens
   Needs that emerge from seeing working software call for iterative Agile prototyping, not a plan fixed up front.
4. Requirements are set by regulation and will not change
   Waterfall moves through fixed sequential phases with requirements locked at the start, so it suits a project whose requirements are stable and well defined.

In the Shannon–Weaver communication model, an interface that drops characters from a lab result while it travels between systems represents:

1. the channel.
   The channel is the medium that carries the message, here the interface itself; the dropped characters are interference on that channel, not the channel.
2. feedback.
   Feedback is the receiver's response returned to the sender; a corrupted result is not a reply.
3. the sender.
   The sender is the source system that originates the result; nothing in the stem describes the source creating a faulty message.
4. noise.
   In the Shannon–Weaver model, noise is anything that distorts or drops part of the message between sender and receiver, such as lost characters in transit.

An informatics nurse wants to build a validated, copyrighted depression screening instrument into an EHR flowsheet. Before building it, the nurse should:

1. reword the items to avoid copyright problems.
   Rewording a validated tool breaks its validation, and a close paraphrase can still infringe the copyright.
2. confirm the license terms for electronic use.
   Many validated instruments are copyrighted and licensed separately for electronic reproduction, so the license has to cover building the tool into an EHR before any build starts.
3. assume clinical use is covered by fair use.
   Fair use is a narrow, case-by-case defense; routinely reproducing a whole instrument across an EHR is unlikely to qualify.
4. cite the instrument's authors in the flowsheet.
   Attribution is good practice but does not grant permission; citing authors is not a license to reproduce copyrighted items.

A hospital receives notice of a malpractice lawsuit involving a patient's care last year. What must the organization do with that patient's EHR data?

1. Release the full record to the plaintiff's attorney
   Records are produced through legal channels such as a subpoena or the patient's authorization, not handed over on receipt of a lawsuit notice.
2. Place a legal hold that suspends routine purging of the record
   Once litigation is pending or reasonably expected, the organization must preserve relevant EHR data, metadata, and audit trails by suspending routine destruction under a legal hold.
3. Amend errors in the notes before records are produced
   Changing records after a claim arrives looks like tampering; legitimate corrections follow the audited amendment process and are not made to prepare for litigation.
4. Continue purging data according to the retention schedule
   Following the normal schedule after notice of a lawsuit destroys evidence and can be treated as spoliation.

Two hospitals in the same system reach identical barcode medication scanning compliance, one through a phased rollout and the other through a big-bang go-live. Which systems theory concept does this illustrate?

1. Entropy
   Entropy is a system's drift toward disorder without input of energy or maintenance; it describes decline, not two routes to one result.
2. Homeostasis
   Homeostasis is a system's tendency to keep a steady internal state through feedback, not the matching of results across different paths.
3. Multifinality
   Multifinality is the reverse idea: similar starting conditions lead to different outcomes. Swapping the two terms is the classic error.
4. Equifinality
   Equifinality is the open-systems principle that the same end state can be reached from different starting points or by different paths, here phased and big-bang rollouts.

A float nurse must view the record of a patient outside the nurse's assignment during a rapid response. Which access control design best balances timely access with privacy?

1. Discretionary access granted by the patient's primary nurse on request
   Waiting for another nurse to grant access delays care in a rapid response and depends on a person being reachable.
2. Facility-wide read access for all nurses, reviewed in annual audits
   Open access for everyone ignores the minimum necessary principle, and once-a-year audits catch inappropriate viewing far too late.
3. Break-the-glass access with a documented reason and audit review
   Break-the-glass lets a clinician override normal access limits in an urgent situation, captures the reason, and flags the access for review, balancing speed with accountability.
4. Strict role-based access limited to the nurse's current assignment
   Assignment-only access protects privacy but blocks the float nurse during an emergency, which puts the patient at risk.

Before running any test cycles on a fall-prevention alert, the team answers three questions: what it is trying to accomplish, how it will know a change made things better, and what changes to try. This is:

1. the Iowa Model of EBP.
   The Iowa Model is an evidence-based practice framework built on triggers and decision points about evidence; confusing EBP models with QI models is a common slip.
2. a Lean value stream mapping.
   Value stream mapping diagrams every step of a process to expose waste and delays; it is a tool, not a set of guiding questions.
3. the Six Sigma DMAIC methodology.
   DMAIC moves through define, measure, analyze, improve, and control phases to cut variation; it does not open with the three questions.
4. the IHI Model for Improvement.
   The Model for Improvement starts with three fundamental questions on aims, measures, and changes, then tests changes in PDSA cycles.

A patient asks that a newly finalized pathology result be released to the portal right away instead of after clinician review. Under federal information blocking rules, the organization generally should:

1. require written authorization before releasing results to the patient.
   Patients have a right to their own information; authorization is for disclosures to third parties, not for giving results to the patient.
2. release it promptly unless an exception like preventing harm applies.
   Under federal information blocking rules, electronic health information goes to the patient without delay; a hold is allowed only if a defined exception, such as preventing harm, fits the specific case.
3. hold it for 72 hours so the clinician can discuss the result first.
   A routine delay so the clinician can speak first is the kind of blanket practice the rule treats as interference, and the patient here has asked for prompt release.
4. withhold it, because HIPAA permits but never requires portal release.
   Treating HIPAA's minimum as the limit ignores the separate federal information blocking duty; withholding available electronic information can be information blocking.

A rehabilitation facility requests a transferred patient's full hospital record to plan ongoing care. How does the HIPAA minimum necessary standard affect this request?

1. It requires the patient's written authorization.
   Treatment disclosures between providers are permitted without written authorization; that requirement belongs to uses outside treatment, payment, and operations.
2. It is not required for disclosures to a provider for treatment.
   The minimum necessary standard is waived for disclosures to a health care provider for treatment, so the hospital may send the record the facility needs to continue care.
3. It requires privacy officer review of each item.
   Item-by-item privacy review is not required for treatment disclosures and would delay care at the point of transfer.
4. It limits release to the discharge summary.
   Nothing in the rule caps a treatment disclosure at a discharge summary; this applies the minimum necessary idea where it does not reach.

A document states that nurses must scan the patient's wristband and each medication before every administration, but it does not list the steps for doing so. This document is a:

1. policy.
   A policy states what must be done and the organization's expectation, here scanning before every administration, without the step-by-step method.
2. procedure.
   A procedure gives the sequential steps for carrying out a task; the stem explicitly says the steps are missing, which is the usual policy/procedure confusion.
3. guideline.
   A guideline offers recommended, flexible direction rather than a mandatory rule; 'must scan before every administration' is not optional.
4. protocol.
   A protocol is a detailed clinical plan for a specific condition or treatment, such as a heparin protocol, not a general organizational requirement.

A ransomware attack encrypts the EHR database, and clinicians cannot open records for 12 hours, although no data are viewed or taken. Which element of the CIA triad was primarily compromised?

1. Accountability
   Accountability, tracing actions to users through logs, is a security goal but is not one of the three CIA triad elements.
2. Integrity
   Integrity concerns data being altered or corrupted without authorization; the main harm here is that no one can use the records.
3. Availability
   Availability means authorized users can reach data and systems when needed; locked-out clinicians for 12 hours is an availability failure.
4. Confidentiality
   Confidentiality is lost when data are viewed or taken by unauthorized people; the stem says nothing was viewed or taken.

Which law directed the creation of the Trusted Exchange Framework and Common Agreement (TEFCA) and defined information blocking?

1. The HITECH provisions of ARRA
   HITECH (2009) funded EHR adoption through Meaningful Use and strengthened HIPAA enforcement, but it predates information blocking and TEFCA.
2. The Medicare Access and CHIP Reauthorization Act
   The Medicare Access and CHIP Reauthorization Act (MACRA, 2015) created the Quality Payment Program and folded Meaningful Use into MIPS; it did not create TEFCA.
3. The 21st Century Cures Act of 2016
   The 21st Century Cures Act of 2016 defined information blocking and directed ONC to develop the Trusted Exchange Framework and Common Agreement.
4. The Affordable Care Act of 2010
   The Affordable Care Act of 2010 reshaped coverage and payment models; it did not create TEFCA or define information blocking.

Graves and Corcoran's 1989 model, foundational to nursing informatics, describes the progression from:

1. information to knowledge to wisdom.
   This drops data, the base level of the model, and adds the later wisdom level.
2. data to information to knowledge to wisdom.
   This is the later DIKW framework; crediting wisdom to the original 1989 model is the most common error.
3. data to information to knowledge.
   Graves and Corcoran's 1989 model described nursing informatics as managing data, information, and knowledge; wisdom was added later, notably in the 2008 ANA scope and standards.
4. data to knowledge to wisdom.
   This skips information, the step where data are organized and interpreted, and adds wisdom, which the 1989 model did not include.

Nurses say they would use a new mobile charting app, but two wings have no reliable Wi-Fi and there are too few charging stations. In UTAUT, these barriers belong to which construct?

1. Facilitating conditions
   In UTAUT, facilitating conditions are the organizational and technical resources, like Wi-Fi coverage and charging stations, that people believe support use of the system.
2. Effort expectancy
   Effort expectancy is how easy the app seems to use; poor infrastructure is not a usability judgment about the app.
3. Behavioral intention
   Behavioral intention is the outcome the nurses already report; it is what the barriers would undermine, not the barriers themselves.
4. Social influence
   Social influence is the pressure from important others to use the technology, which the stem does not mention.

A hospital is choosing a new EHR and wants to keep participating in the Medicare Promoting Interoperability Program. The selected product must be:

1. certified to ONC health IT certification criteria.
   The Promoting Interoperability Program requires certified EHR technology, meaning a product certified under the ONC Health IT Certification Program.
2. validated at HIMSS EMRAM Stage 7.
   EMRAM stages are a voluntary HIMSS maturity benchmark; no CMS program requires them.
3. approved by the FDA as a medical device.
   EHRs are generally not regulated as devices, and FDA clearance has nothing to do with Promoting Interoperability participation.
4. accredited by The Joint Commission for inpatient use.
   The Joint Commission accredits health care organizations, not software products.