NURS FPX 6410 Executive Summary to Administration

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Importance of a HIPAA Compliant Spreadsheet

NURS FPX 6410 Executive Summary to Administration

Healthcare organizations have the responsibility to establish mechanisms for storing and sharing information that complies with federal regulations.  Those regulations were enacted in 1996 as the Health Insurance Portability and Accountability Act (HIPAA) was amended in 2009 in the Health Information Technology for Economic and Clinical Health Act (HITECH) to speak to the challenges due to the sensitive nature of the information stored within electronic health records (EHR) (Kruse et al, 2017). HIPAA is considered one of the most important health safeguards that legislation has in place. This Act cleared the way for a national standard for the protection and privacy of health data. The regulations were established to prevent fraud and ensure security by restricting access of patients’ health data to persons who have authorization.

NURS FPX 6410 Executive Summary to Administration

HIPAA’s primary objectives were to ensure patients felt confident in providing their sensitive information to healthcare organizations, while also sanctioning reasonable information flow for treatment, public health needs, operations, and research. (Cohen, 2018) The act has established this by guaranteeing that health care staff, clearing houses, insurance plans and other health care organizations follow the standards set forth by executing safety measures to secure confidential and sensitive information. The regulations shape the restrictions of sharing and viewing patient information unless it is for patient care.  Patient care information per HIPAA, that is created, stored, transmitted, or disclosed is subjective to rigorous security protocols.  Under those conditions, a HIPAA-compliant spreadsheet would ensure the privacy and confidentiality of patient health data.

 Utilizing an Informatics Theory to Affect Change

In the Neonatal Intensive Care Unit at Kaiser Permanente, the Nursing Informatics Progression Theory has been applied to the computer monitoring systems called EPIC, which is also linked to the individual bedside monitor.  Many advanced technologies have become readily available over the years that have positively affected how nurses perform their daily regimen but were easy to initially accept. (Cassano, 2018). Within the (NIPT) there are four steps to adaptability. These four steps are assimilation, acceptance, application, and advancement has made it possible for nurses to have an easier transition to the change in technology and especially when it comes to EPIC. (Cassano, 2018) Kaiser Permanente is the originator of EPIC that began in 1994 but transitioned to all healthcare in 2003. (Bornstein, 2012)

Utilization of Standard of Practice

One’s performance can be evaluated by professional practice standards.  Those standards set the bar of the desired level of performance to be obtained.   The primary goal of nursing standards is to assist in directing and preserving a safe and competent practice in nursing. (Davis, 2015) The American Nurses Association has two sets of standards that are followed. The 2015 revision Nursing Scope and Standards of Practice and Standards of Practice for Nursing Informatics. The universal Nursing Code of Ethics is supported by the ANA standards of practice.  The Nursing Code of Ethics includes avoiding illness, promoting health, mitigate suffering and restoring health. (AMA, 2015)

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Being that this information was based on the NICU at Kaiser Permanente, the ethical and business standards were applied properly and modern EMR technology has improved healthcare for the infant population but what does not apply to this population is the concern of conventional patient provider interaction.  Nursing in the NICU is primary care nursing.

The Standards of Practice used for Nursing Informatics explicitly directs how informatic nurses and specialists achieve the nursing process. It is a valuable asset for those in the field of education, bedside, administration, and research.  Inside those standards, there is an essential connection between technology, the patient, and the medical care providers that promote a positive outcome. 

NURS FPX 6410 Executive Summary to Administration

Regulatory Information

  Patient’s information security and privacy are tantamount to guaranteeing their trust in the modern era of EMR.  It has become a healthcare organization’s major priority to manage and safeguard personal patient information.  Kaiser Permanente has not only established, implemented, and organized these protections as mandated by law, HIPAA they have also added other protective measures. EPIC created a privacy tool called, “Break the Glass.”  It was famously utilized in 2009, when the Octomom was admitted and doctors, nurses, and even evs workers who had no reason to enter the chart were attempting to gain confidential information. The security screen automatically requires the user to enter a reason access to the record is needed to a record marked sensitive. Data breaches and their reporting was addressed in the HITECH Act by the formation of distinct protocols for the various organizations and facilities associated with health care that should be followed. Each organization has a distinct set of guidelines that must be followed. (Kruse, 2017)


Complying with HIPAA regulations guarantees that a healthcare organization like Kaiser Permanente maintains the security and confidentiality of their patient information within their EHR known as EPIC. This decreases the chance of patient record errors and restricted access to authorized individuals. This has especially been effective for the NICU because there are other family members who care about the infant who is sick but are not entitled to their medical information or updates; such as grandparents. 

Excel Spreadsheet Note


It is evident that the NICU patients that were 30 weeks and less had a longer stay but increase hospital cost than those NICU patients were greater than 30 weeks and a shorter stay. 

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American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: American Nurses Association.

Cassano, C. (2018). Nursing informatics progression theory (NIPT): The 4a’ of adaptability.

Nursing and Primary Care, 2(1), 1-6. 

NURS FPX 6410 Executive Summary to Administration

Cohen, I. G., & Mello, M.M. (2018). HIPAA and protecting health information in the 21st

Century.  Journal of the American Medical Association, 320(3), 231-232.

Davis, C. (2015). The importance of professional standards. Nursing Made Incredibly Easy!,


Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017). Security techniques for the electronic health records. Journal of Medical Systems, 41(127), 126-136.

Martin, N. L. Imboden, T., & Green, D. T. (2015). HIPAA security rule compliance in small healthcare facilities:  A theoretical framework.  Issues in Information Systems, 16(1),  180-188.