ANCC Informatics Nursing 1 — Questions and Answers
Question 1: A CDS alert fires 400 times per month but 92% are overridden by clinicians. This phenomenon is called:
- Clinical relevance failure
- Alert fatigue (Correct answer)
- False negative error rate
- Usability deficit
Correct answer: Alert fatigue
Alert fatigue occurs when clinicians are overwhelmed by excessive, low-specificity alerts and begin routinely overriding them without adequate evaluation, including clinically significant alerts.
Alert fatigue is a major unintended consequence of CDS implementation. Override rates above 90% mean critical alerts are dismissed without consideration. Contributing factors: poor specificity with many false positives, irrelevant timing, duplicate alerts, excessive severity thresholds. Informatics interventions: alert tiering (critical vs. advisory), evidence-based review committees, increasing specificity, removing low-value alerts, monitoring override rates as a quality metric, and role-based contextual alerts.
Question 2: Which level of informatics competency is expected of ALL nurses regardless of specialization?
- Ability to develop new clinical information systems
- Basic computer and information literacy including EHR documentation and data retrieval (Correct answer)
- Proficiency in programming and database query languages
- Leadership of health IT implementation projects
Correct answer: Basic computer and information literacy including EHR documentation and data retrieval
All nurses are expected to have foundational informatics competencies: basic computer literacy, EHR use for documentation, retrieval of patient data, and use of electronic resources to support patient care.
Nursing informatics competency frameworks (ANA and TIGER Initiative) define three levels: beginning nurse with basic computer skills, EHR documentation, electronic MAR, basic data retrieval, and CDS use; experienced nurse with advanced EHR functions and QI data use; and informatics nurse specialist with system design, implementation, evaluation, and analytics leadership. QSEN includes informatics as one of six core competencies for all nursing graduates.
Question 3: Which principle of human factors engineering is most important when designing a medication reconciliation workflow in the EHR to prevent medication errors?
- Increasing the number of alert pop-ups to ensure every discrepancy is flagged
- Designing systems that make it easy to do the right thing and difficult to make an error using forcing functions and error proofing (Correct answer)
- Requiring nurses to memorize the medication reconciliation steps
- Allowing each unit to develop its own custom medication entry screens
Correct answer: Designing systems that make it easy to do the right thing and difficult to make an error using forcing functions and error proofing
Human factors engineering aims to design systems that align with human cognitive capabilities, use forcing functions to prevent errors, and reduce reliance on memory.
HFE applied to health IT uses: forcing functions (system prevents action until required step is completed); standardization to reduce variability; simplification to reduce steps and clicks; redundancy with double-check mechanisms for high-risk medications; fail-safes that default to safe state; and feedback with confirmation screens. The IOM report 'To Err is Human' emphasized errors are predominantly system design failures. Alert overload and custom fragmented systems increase error risk.
Question 4: Which of the following best describes interoperability in health information technology?
- The ability of a hospital EHR to generate billing reports
- The ability of different health information systems to exchange and use clinical data seamlessly (Correct answer)
- Security encryption used to protect patient data
- The process of converting paper records to electronic format
Correct answer: The ability of different health information systems to exchange and use clinical data seamlessly
Interoperability refers to the ability of different health information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner.
HIMSS defines four levels: (1) Foundational — basic connectivity; (2) Structural — standardized format using HL7 and FHIR; (3) Semantic — common codification (SNOMED CT, LOINC, RxNorm, ICD-10) for shared meaning; (4) Organizational — governance and legal frameworks. HL7 FHIR is the current standard for API-based health data exchange. The 21st Century Cures Act mandates interoperability and prohibits information blocking.
Question 5: Which usability testing method involves observing nurses performing real tasks in the EHR and measuring time-on-task, errors, and satisfaction?
- Expert heuristic evaluation
- Formative usability testing with think-aloud protocol
- Summative usability testing with task-based performance metrics (Correct answer)
- Cognitive walkthrough by the design team
Correct answer: Summative usability testing with task-based performance metrics
Summative usability testing measures actual performance outcomes (task completion rates, time-on-task, error rates, satisfaction scores) with representative users performing realistic tasks. It quantifies usability for go/no-go decisions.
EHR usability testing methods: (1) Heuristic evaluation — experts review against Nielsen's 10 heuristics without real users; (2) Cognitive walkthrough — design team mentally simulates user steps; (3) Formative testing — during development using think-aloud protocol, qualitative focus; (4) Summative testing — on completed system measuring quantitative performance: task completion rate, time-on-task, error rate, and user satisfaction using the System Usability Scale (SUS). Required by NIST and ONC for EHR certification.
Question 6: Under HIPAA, which represents a permitted use of PHI without requiring patient authorization?
- Sharing a patient's HIV status with their employer for workplace accommodation
- Selling de-identified patient data to a pharmaceutical company for marketing
- Disclosing PHI to another treating provider for care coordination (treatment purpose) (Correct answer)
- Providing a patient's mental health records to their family member upon family request
Correct answer: Disclosing PHI to another treating provider for care coordination (treatment purpose)
HIPAA permits covered entities to use and disclose PHI without patient authorization for treatment, payment, and healthcare operations (TPO). Sharing with another treating provider falls under the treatment exception.
HIPAA Privacy Rule permits PHI use/disclosure without authorization for: (1) Treatment — care coordination, referrals, consultation; (2) Payment — billing, claims, prior authorization; (3) Healthcare Operations — QI, training, audits. Other permitted disclosures: public health activities, abuse/neglect reporting, health oversight, judicial proceedings, law enforcement (limited), and national security. Disclosures requiring authorization: most employer disclosures, sale of PHI, marketing use, psychotherapy notes, and substance abuse records. Family members may receive information when involved in care unless patient restricts it.
ANCC Informatics Nursing 1
A CDS alert fires 400 times per month but 92% are overridden by clinicians.
This phenomenon is called: