NUR-514 Benchmark – Electronic Health Record Implementation Paper

NUR-514 Benchmark – Electronic Health Record Implementation Paper

An electronic health record (EHR) refers to an electronic form of the traditional patient’s medical file kept by the health provider over time. It contains information from administrative and clinical encounters between patients and their health providers during patient care. The EHR also supports other patient care-related activities through interfaces, such as evidence-based decision support, outcomes reporting, and quality management (Schopf et al., 2019). This paper aims to discuss components of designing and implementing the EHR, the professional, ethical, and regulatory standards that should be incorporated, and leadership skills needed for collaboration of the interprofessional teams.

Key Information Needed in the Database to Track Opportunities for Care Improvement

The EHR support providers make better decisions and improve patient care quality. It achieve

s this by improving the accuracy and clarity of medical information, which reduces the occurrence of medical errors (Schopf et al., 2019). The EHR also makes health data available and easily accessible, reduces duplication of services, reduces treatment delays, and empowers patients to make better health decisions. Patient information is needed in the EHR database to help identify opportunities for patient improvement. The key patient information includes demographics, current medical problems, past medical and surgical history, medications, vital signs, immunization history, progress notes, laboratory results, and imaging reports (Schopf et al., 2019). The information can predict a patient outcome which helps to provide appropriate interventions to achieve the best possible outcomes (Schopf et al., 2019). It can also identify risk factors for a disease or complications and guide providers to take prior preventive interventions.

Role Informatics Plays in the Ability to Capture This Data

Informatics deals with computational systems, particularly with systems that involve data storage and retrieval. The role of

informatics in facilitating the capturing of the data in EHR databases includes providing tools with clinical and operational applications that help health organizations capture health information in EHRs to advance medical care (Aguirre et al., 2019). Informatics help organize patient data collected from a myriad of devices and systems such as electronic medical records, patient portals, health tracking devices, and diagnostic systems (Aguirre et al., 2019). Informatics captures the data from all these devices, which is usually in different formats, and converts it to a single format stored in the database. For instance, database management systems have programming interface applications that transmit connections between databases and are used to process complex health information across various platforms.

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The Systems and Staff Members that Would Need to Be Involved in the Design and Implementation Process and Team

Implementation of the EHR will entail handling a wide range of medical information across various medical settings. Therefore, it will be important to incorporate a range of systems that will convert the information in real-time and upon request. Systems that will be required in the EHR include Documentation system, Billing and reimbursement system, E-prescribing, and Report generation systems. The documentation system will facilitate electronic charting and enable information to be well-structured and easily accessible to practitioners and patients (Aguirre et al., 2019). The billing and reimbursement system will facilitate easy payment of health services and ease reimbursement with insurance companies. The E-prescribing system will help track prescribed medications, evaluate medications for allergies, side effects, and interactions, and enable clinicians to make quick decisions regarding patients’ medication (Aguirre et al., 2019). Furthermore, the report generation system will enable providers to develop reports using specific information like demographics, medication, and procedures.

The EHR team will be sourced from key internal stakeholders and external consultants. The team will be composed of a project manager, application analyst, application developer, QA Test Engineer, physician, nurse, billing advocate, and super-users. The project manager will be the team leader and will be responsible for keeping the team focused on the project and timelines and will address user issues (Aguirre et al., 2019). The application analyst will be responsible for data migration and cleansing, while the application developer will be tasked with system customization. The QA Test Engineer will be responsible for system testing and performance. The physician, nurse, and billing advocates will represent physicians, nurses, and billing departments, respectively, and advise on training, data, and testing (Aguirre et al., 2019). Lastly, the super-users will be the early adopters for the EHR implementation training programs.

Professional, Ethical, and Regulatory Standards That Must Be Incorporated Into the Design and Implementation of the System

Professional standards that must be incorporated in the EHR design and implementation include completing a risk analysis of the system, encrypting electronic health information, and obtaining a HIPAA-compliant business associate agreement. According to Lee (2017), system users must be advised to report when data breaches occur immediately. Ethical standards must be incorporated by ensuring that patient health information is protected, including billing information, claims processing, enrollment status, diagnostic notes, and clinic visit notes (Lee, 2017). Ethical standards that must be incorporated in the implementation include adhering to patient confidentiality laws such as the Directory information rule, Treating physician rule. Social media rule and Business Associate Agreement rule. Regulatory standards must be integrated by complying with the HIPAA and HITECH regulations (Lee, 2017). The design and implementation team will ensure that HIPAA and HITECH regulations are followed during EHR software development, including its design, programming, and distribution.

How the EHR Team Would Ensure That All Order Sets Are Part of the New Record

Order sets refer to a group of orders that standardize and accelerate the ordering process for a specific clinical case. Order sets that are standardized and up-to-date facilitate the application of clinical decision support (CDS) at the point of care (Yang, Kang & Lee, 2016). The EHR team can ensure that all order sets are part of the new record using small groups of clinicians with multidisciplinary representation to curate order sets based on clinical guidelines, organizational policies, and expert opinion (Yang et al., 2016). The group should be tasked with approving, reviewing, and maintaining Clinical Ordered Sets in the new EHR. The EHR team can also create a clinical content strategy containing the best clinical practices and the organization’s standards with data content sources (Yang et al., 2016). Furthermore, the EHR team can develop a process that identifies and replaces obsolete content in the order sets that have potential adverse effects on patient safety and patient care quality.

Communication of the Changes, Including Any Kind of Transition Plan

Communication to the rest of the staff about the new EHR would be made through super-users and internal memos. The super-users will be provided in-depth training on all aspects of the EHR system to enable them readily understand and answer questions from the staff about the EHR (Aguirre et al., 2019). They will communicate to the staff on a face-to-face basis in organization meetings and CME programs. They will train the staff on the EHR, including its components and benefits in healthcare delivery. Internal memos will communicate to the staff about any changes in the EHR system and outline the implementation process.

Measures and Steps to Evaluate the Success of the EHR Implementation

The success of the EHR implementation will be measured from the staff, setting, and patient perspective, which will help identify improvement areas. To evaluate EHR implementation success from the staff perspective, I will conduct a survey to measure health providers’ satisfaction with the EHR (Aguirre et al., 2019). In the survey, I will ask them to rate how the EHR implementation has eased healthcare delivery, such as access to patient information, evidence-based decisions, and documentation. The EHR’s success in the healthcare setting will be measured by analyzing data error rates to evaluate how the EHR has improved data input and quality (Aguirre et al., 2019). I will also conduct return on investment (ROI) calculations to measure the EHR’s profitability. Furthermore, the EHR’s success will be measured by surveying patients’ satisfaction with the quality of care. I will also measure patients’ wait times to assess if providers can process patients promptly.

Leadership Skills, Theories, and Styles to Employ for Collaboration on Interprofessional Teams

Leadership skills essential to facilitate collaboration in the interprofessional team include organizational, communication, and conflict resolution skills. The interprofessional team leader needs organizational skills to be able to delegate responsibilities, coordinate the team’s duties and workload, and keep the team organized (Folkman, Tveit & Sverdrup, 2019). Communication skills enable the leader to demonstrate clear and thoughtful communication that fosters a collaborative environment and communicates the team’s goals (Folkman et al., 2019). Conflict resolution skills are essential to enable the team leader to solve conflicts, which arise in the interprofessional team. They are also vital in promoting cooperation and unity within the interprofessional team.

Transformational leadership theory would promote collaboration in the interprofessional team by motivating the team to work towards a common goal. The leader can share a vision based on the envisioned patient outcomes and guide the team toward coming closer to the vision (Folkman et al., 2019). The participatory leadership style would promote collaboration within the interprofessional team as it encourages members to participate in decision-making (Folkman et al., 2019). Members of the interprofessional team can be encouraged to provide evidence-based interventions that can promote high-quality patient-centered care.

Conclusion

The EHR is an electronic tool that improves and eases patient information access and streamlines health providers’ workflow. The EHR database should contain a patient’s demographic information, comprehensive medical history, and progress notes. Informatics helps capture this information by organizing patient data from multiple sources and converting it to one in the EHR format. The EHR team should include internal stakeholders and external consultants and be handed different responsibilities. When designing and implementing the EHR, professional, ethical, and regulatory standards should be observed by maintaining patient confidentiality and complying with HIPAA and HITECH regulations. Organizational, communication, and conflict resolution skills are vital in promoting the interprofessional team’s collaboration. Besides, transformational leadership theory and democratic leadership can be applied to promote interprofessional collaboration.

References

Aguirre, R. R., Suarez, O., Fuentes, M., & Sanchez-Gonzalez, M. A. (2019). Electronic health record implementation: a review of resources and tools. Cureus, 11(9), e5649. https://doi.org/10.7759/cureus.5649

Folkman, A. K., Tveit, B., & Sverdrup, S. (2019). Leadership in interprofessional collaboration in health care. Journal of multidisciplinary healthcare, 12, 97–107. https://doi.org/10.2147/JMDH.S189199

Lee, L. M. (2017). Ethics and subsequent use of electronic health record data. Journal of biomedical informatics, 71, 143-146.https://doi.org/10.1016/j.jbi.2017.05.022

Schopf, T. R., Nedrebø, B., Hufthammer, K. O., Daphu, I. K., & Lærum, H. (2019). How well is the electronic health record supporting hospital physicians’ clinical tasks? A survey of physicians at three Norwegian hospitals. BMC health services research, 19(1), 1-9. https://doi.org/10.1186/s12913-019-4763-0

Yang, J., Kang, U., & Lee, Y. (2016). The clinical decision support system in the medical knowledge literature review. Information Technology and Management, 17(1), 5-14. https://doi.org/10.1007/s10799-015-0216-6

The current health practice has evolved in multiple dimensions, including better clinical systems, increased access, and more emphasis on patient-centered care. As these developments occur, technology has been instrumental in evolving critical patient care dimensions. As a result, nursing informaticists and other healthcare practitioners should embrace innovation and guide their organizations in tracking care improvement opportunities and intervening appropriately. For innovation to succeed, healthcare facilities should have the appropriate culture and resources to support and facilitate change (Sharplin et al., 2019). Advanced practice nurses should also play their role as change leaders effectively. The purpose of this paper is to discuss an opportunity for care improvement and the necessary considerations for implementing a new electronic health record (EHR) system.

An Opportunity for Tracking Care Improvement and Database Information

When visiting healthcare facilities, patients always look forward to a comprehensive analysis of their conditions. However, such care can only be achieved if the facilities have efficient and up-to-date EHR systems and other tools for clinical decision support. Effective EHR systems improve care efficiency and reduce inconveniences occasioned by medical errors (Kehsta & Odeh, 2021). A suitable opportunity for tracking care improvement is a system’s task completion rate. In everyday practice, systems’ inefficiencies hamper care outcomes by causing treatment delays or failing to facilitate quick information sharing between providers. An upgrade of the system’s operating system can produce better results in such instances. The other option is implementing a new EHR system to capture patient data easily, enable quick analysis, and ensure that practitioners can share crucial data in real time.

A database contains essential health information to guide practitioners in decision-making. In clinical settings, a database should allow clinicians to store information in a way that can be accessed and managed easily. Appropriate data updates should also be done conveniently. Key information in the database should be primarily about patients. Such information includes patients’ demographics, problems, and current medications (CMS.gov, 2023). The other crucial information relevant to clinicians and patients includes progress notes and time spent during the care process. Further analysis of the time spent during the care process can indicate whether the new EHR system requires improvements.

Role of Informatics in Data Capturing and Project Management Strategies

Informatics is at the center of healthcare evolution and plays an instrumental role in promoting data-driven care. According to Estiri et al. (2018), informatics allows clinicians to capture information rapidly to facilitate quick decision-making. Through informatics, patient information can also be captured in multiple formats, although organizations must have highly interoperable systems to use such data effectively. The implication is that the clinical setting embracing informatics would benefit from quick information capturing, further improving collation, analysis, storage, and retrieval.

Implementing system changes typifies engaging in a project designed to improve patient outcomes. Essential project management strategies and methodologies include teamwork, planning, design, and implementation. Teamwork is crucial in improving quality in clinical practice since it allows people to share perspectives and address a common issue creatively. Regarding system changes, Aguirre et al. (2019) underlined that EHR implementation could be challenging hence the need for effective planning to minimize errors. The planning phase is broad since it entails assessing the selection criteria of teams and intended system performance, including interoperability and confidentiality. Concerning design, maximum consideration of the infrastructure is crucial to ensure clinicians are provided with a robust system and tools to transform practice (Estiri et al., 2018). Implementation denotes putting the system into use. In the current context, it should be implemented after successful piloting and when users can use it comfortably and effectively.

Systems, Staff Members, and the Role of the Advanced Registered Nurse

System implementation should be a collaborative task. Such an approach is crucial since diverse leaders and healthcare teams have different skills and competencies, which are essential in informed decision-making. In clinical practice, shared perspectives improve decision-making since information can be analyzed and critiqued (Roodbeen et al., 2021). Systems necessary in the design and implementation process include communication and health information technology (IT) systems. Communication systems are crucial for enabling healthy interaction between team members, while IT systems are valuable for data collection, analysis, and other related functions. Staff members include the organization’s management, IT department members, system analysts and designers, nurse leaders, and nurses as the end users. Involving nurses as the end users is vital since they will be interacting with the system regularly. Hence, they should understand its basic features, functionality, and how to use it for optimal patient care.

Successful organizations should be open to change and support innovation. Consequently, they should promote evidence-based practice (EBP) and support quality improvement initiatives. As Sharplin et al. (2019) suggested, EBP thrives in a culture ready for change and in organizations that support and reward innovation. In this setting, advanced registered nurses are mandated to identify opportunities for quality improvement and propose interventions for enhancing outcomes. For instance, advanced practice nurses design education programs to reduce infections and improve health literacy. This implies that they are pivotal in practice transformation and ensuring progressive improvement in healthcare processes and outcomes.

Strategies for Implementing the New EHR Proposal

The new EHR system is expected to improve clinical outcomes and have new features, including design, themes, and layout. As a result, communication about the proposed changes is essential to ensure its targeted users are mentally ready for it. Readiness for change reduces possible resistance hence quick implementation (Sharplin et al., 2019). When everyone is ready, a transition to the new system can occur. Here, clinicians would start using the new EHR system to perform tasks quicker than the previous system. A crucial component of the transitioning process is user education to ensure nurses and other users can use the system competently and confidently. Teamwork should also be encouraged before everyone is conversant with the new system. Change leaders should also monitor nurses’ experience with the new system and intervene in areas where user challenges are witnessed. Doing so would allow leaders to design post-implementation support for the sustainable use of the new EHR system.

Professional, Ethical, and Regulatory Standards

EHRs are the foundation of health information exchange. They facilitate the exchange of protected health information (PHI) hence the need for compliance with the established standards. Professional standards that must be incorporated into the system’s design and implementation include user-centeredness and interoperability. User-centeredness can be achieved by an institutive design that is user-friendly to encourage healthcare professionals to use a system (Micheal et al., 2021). Interoperability entails a system’s capacity to share information among different users. It should also be a priority area since interoperable systems should be convenient and safe to use.

The most crucial ethical standards to consider are security, privacy, and confidentiality. The system should be secure from internal and external attacks that can hamper its efficiency. Effective system security is achieved by implementing appropriate safety measures. A secure EHR system is also able to protect patients’ private information (Kehsta & Odeh, 2021). Confidentiality is achieved by ensuring identifiable health information is inaccessible to unauthorized users. Regarding regulatory standards, the EHR system should adhere to the principles of meaningful use. In this case, all the design considerations should enable healthcare professionals to use the system to improve care outcomes such as quality and safety. For instance, quick information sharing would improve care quality and patient satisfaction due to timely care.

Success Evaluation

EHR system implementation can be tedious and time-consuming. Evaluating outcomes would help to determine whether the desired goals were achieved. From a staff perspective, the EHR system should improve communication and teamwork between clinicians. Effective communication and sustained teamwork are the foundation of interprofessional collaboration (Schot et al., 2020). Other outcome measures include improved efficiency (task completion speed) and patient care characterized by minimal errors and treatment delays. The setting would benefit from teamwork and efficiency to increase its productivity, leading to higher revenue. Efficient systems also enhance job satisfaction, reducing fatigue and other potential causes of staff burnout. From a patient perspective, the system’s success could be evaluated by increased satisfaction, reduced treatment delays, and better patient-provider interaction. The implication is that patient experience would improve, and failure to achieve these goals would necessitate further practice improvements.

Leadership Skills and Theories for Collaboration and Evidence-Based, Patient-Centered Care

An interprofessional team comprises members with diverse skills and roles. Keeping such a team motivated and glued to accomplishing its role is a critical success factor. Leadership skills crucial in facilitating collaboration with the interprofessional team include open communication, dialogue, and respect. It is crucial for all team members to be respected, irrespective of their ranks and roles. Open communication and dialogue encourage sharing information and ensure all perspectives are incorporated in decision-making (Albert et al., 2020). The transformational leadership theory would facilitate collaboration with the team and provide evidence-based, patient-centered care. According to Collins et al. (2020), transformational leadership focuses on empowering and motivating the team by utilizing a leader’s influential attributes and behaviors. In a transformative approach, the leader carries the team’s vision and inspires the team to work together for a shared purpose. A similar approach would be required in the EHR system implementation due to the diverse nature of team members.

Conclusion

Healthcare organizations require efficient systems for the continuous delivery of high patient outcomes. As a result, appropriate system changes should be encouraged to ensure clinical settings benefit from technology and informatics as they strive to optimize patient outcomes. When designing and implementing a new EHR system, nurses and other change leaders should be guided by professional, ethical, and regulatory standards. Adherence to these standards would ensure the system complies with the foundation principles of standard practice. Since system design and implementation require teamwork, transformational leadership should be highly recommended. A transformational approach encourages shared decision-making as the team work together to achieve a shared vision.

 

 

References

Aguirre, R. R., Suarez, O., Fuentes, M., & Sanchez-Gonzalez, M. A. (2019). Electronic health record implementation: a review of resources and tools. Cureus, 11(9), e5649. https://doi.org/10.7759/cureus.5649

Albert, N. M., Pappas, S., Porter-O’Grady, T., & Malloch, K. (2020). Quantum leadership: Creating sustainable value in health care. Jones & Bartlett Learning.

CMS.gov. (2023). Electronic health records. https://www.cms.gov/Medicare/E-Health/EHealthRecords#:~:text=An%20Electronic%20Health%20Record%20(EHR,progress%20notes%2C%20problems%2C%20medications%2C

Collins, E., Owen, P., Digan, J., & Dunn, F. (2020). Applying transformational leadership in nursing practice. Nursing Standard (Royal College of Nursing (Great Britain): 1987), 35(5), 59–66. https://doi.org/10.7748/ns.2019.e11408

Estiri, H., Patel, C. J., & Murphy, S. N. (2018). Informatics can help providers incorporate context into care. Jamia Open, 1(1), 3-6. https://doi.org/10.1093/jamiaopen/ooy025

Keshta, I., & Odeh, A. (2021). Security and privacy of electronic health records: Concerns and challenges. Egyptian Informatics Journal, 22(2), 177-183. https://doi.org/10.1016/j.eij.2020.07.003

Michael, C. L., Mittelstaedt, H., Chen, Y., Desai, A. V., & Kuperman, G. J. (2021). Applying user-centered design in the electronic health record (EHR) to facilitate patient-centered care in oncology. AMIA … Annual Symposium Proceedings. AMIA Symposium, 2020, 833–839. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075506/

Schot, E., Tummers, L., & Noordegraaf, M. (2020). Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. Journal of Interprofessional Care, 34(3), 332-342.

Roodbeen, R. T. J., Noordman, J., Boland, G., & van Dulmen, S. (2021). Shared decision making in practice and the perspectives of health care professionals on video-recorded consultations with patients with low health literacy in the palliative phase of their disease. MDM Policy & Practice, 6(1), 23814683211023472. https://doi.org/10.1177/23814683211023472

Sharplin, G., Adelson, P., Kennedy, K., Williams, N., Hewlett, R., Wood, J., Bonner, R., Dabars, E., & Eckert, M. (2019). Establishing and sustaining a culture of evidence-based practice: an evaluation of barriers and facilitators to implementing the best practice spotlight organization program in the Australian healthcare context. Healthcare (Basel, Switzerland), 7(4), 142. https://doi.org/10.3390/healthcare7040142