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NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper

NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper

NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper

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The process of implementing a new electronic health record (EHR) system is not an easy task for the various stakeholders involved in a healthcare setting, that is, from the decision-makers to the emergency department (Bushman, 2018). The purpose of this paper is to evaluate the significance for effective leadership skills to coordinate an interprofessional team and offer evidence-oriented, patient-based care and application of professional, legal and ethical standards of practice that would provide effective and safe healthcare services. Appropriate utilization of leadership competencies and change management models are critical for effective implementation of the EHR system (Health IT, 2019).

Informatics tools such as electronic health record systems (EHRs) are critical in recording adverse events. At the patient level, EHR enhances communication since unrecorded events will not be communicated (de Hoon et al., 2017). This communication is crucial when multiple healthcare providers are involved in patient care, especially since patient care becomes more complex. Moreover, Rochefort et al. (2015) highlight that natural language processing (NLP) of dictated electronic radiology reports or discharge summaries are informatics tools that can be used to report adverse events. NLP refers to automated methods for converting free-text data into a computer-understandable format.

Informatics and Data Management

A computerized database system is an essential requirement to receive litigable and structured data that is easy to search and trace healthcare environment opportunities. EHR as a diagnostic information system is an extensive system that involves simple access to patient data at the point of care, organized and litigates information that can be readily searched and is suitable for data mining and analysis; and enhanced patient safety, in particular preventing adverse drug reactions and identifying health risk factors such as falling (DeNisco& Barker, 2015). Florence Nightingale’s days are pre-dated by nursing records. Information on nursing has improved its significance to nurses and medical practitioners over time and its effect on patient care and results (Bushman, 2018). The documentation method, from a trail of evidence to an electronic trail, has changed. Health information systems involve the management of health information and utilize IT to organize health records to enhance health results and handle data gathering from patient records (Creasey, 2018).  Health informatics staffs are responsible for managing, interpreting, and sharing health information with the main aim of enhancing care efficiency (Hodgkins, 2015).

Patient care begins with collecting the health history of clients, predisposing factors, history of allergies, and the recent list of medications. In the electronic database, this data is gathered and recorded. Health data can be collected and recorded in real-time by nurses as well as other health experts (DeNisco& Barker, 2015). Reducing prescription failures with the inclusion of “soft stops,” drug allergy alerts and interaction medicines are, therefore, one of the ways to enhance patient safety and have an extensive clinical scheme, which is a wonderful opportunity (Bushman, 2018).

Necessary Regulations for Application of the EHR System

A collaborative team strategy will be needed to guarantee that all the required laws from security and privacy

NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper
NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper

regulation imposed by the federally, design practice business processes, training of care providers and handling the application process for the application of EHR systems are followed. To maintain an interdisciplinary team, a leader is required (DeNisco& Barker, 2015). The type of innovative management that contributes to achievement is servant leadership. As health care and servant management are essential partners, servant leadership is not a fresh concept (Rupp, 2014). Guiding the interdisciplinary team is an efficient way of management. First, the servant leader is a leader whose deliberate decision enables him/her to manage the multidisciplinary team that will involve shareholders from within and outside (Health IT, 2019). Internal participants are doctors, nurses, health and caring personnel, IT employees, developers of EHR, and organizational employees. Patients, domestic EHR suppliers, and technology firms are external shareholders (Hodgkins, 2015).

Professional, Ethical and Regulatory Standards Prerequisites

“Patient care” is complex by the legislative privacy laws and ethical considerations. Health Insurance Portability and Accountability Act (HIPPA) of 1996 is a federal law protecting health data. The HIPAA rules on privacy and safety preserve the confidentiality of protected information health data (DeNisco& Barker, 2015). The Data protection rule applies to protected patient information in any form of expression, while the safety rule applies to electronic protected health data. Within the United States, the web of complex moral and ethical statutes has made it incredibly difficult in the expanding field of health-related research in this area of customer-centered results research. This may be the foundation of affirmative consent practice (Bushman, 2018). The confidentiality process to any medical attention or analysis cooperation must also include relevant information for the patient or facilitator to comprehend the course of treatment, risks, rewards, alternate solution courses offered and the reality that consent may be revoked at any time (Hodgkins, 2015).

Communication and Order Sets

The proof-based technique is the current reality in the field of healthcare coverage. The present use of diagnostic order, consistent with EHR proof-based requirements, has shown a significant decrease in failures and enhanced results. The EHR group will also have to guarantee that all order sets have been integrated into the scheme for appropriate and modified order sets. A structured governance system spurred by the Lead Physician should be maintained to make it useful in this undertaking, afford-in, and contentment from physicians (Creasey, 2018). Diagnostic order sets should reflect policies and procedures and organizational regulations, including the identification and selection of sources of data material, information review, retention, and updating. This is particularly when diagnostic information is sharply tailored, as it will allow considerably more time and commitment to preserving personalized information (DeNisco& Barker, 2015).

Communication is a very significant instrument (Creasey, 2018). Change management is a collection of principles, methods, and prescription medications applied to the human elements of implementing considerable change programs. To make change occur, it enables if the whole organization wishes it to occur. This might assist organizations to spark the original motive to get things moving. To introduce a new EHR scheme, various means of communication are required to inform participants of the modifications that are taking place (Bushman, 2018).

Analysis of the Progress of EHR Implementation

A set of variables of what achievement will sound like should be created before execution. John Kotter’s 8-step framework for efficient transition can provide a directive for deliverables at every stage of performance. Short wins and deliverables are some of the objectives that can be set throughout the original plan subject to implementation (Creasey, 2018). Some of the achievements and priorities which can be set are the evaluation of internal stakeholders ‘ willingness to transform, the scheduling on how to “go-live” based on the evaluation, and the achievement of productive use (Bushman, 2018). Vigilant training at the start is essential to the effective execution of the EHR, but following a set of reasonable expectations and a controllable schedule is crucial. Once implementation is completed, ongoing monitoring is required to assess how inner participants are using the new scheme. This monitoring will guarantee the continuing effective execution of the EHR (DeNisco& Barker, 2015).

Conclusion

Implementation of a new EHR scheme will require considerable planning, buy-in from all decision-makers, and use performance management instruments to move the shift forward. Mapping the application of this fresh EHR scheme as a trip, not just a departure point, will guarantee achievement. Effective communication and successful management are essential considerations in the successful application of an innovative EHR scheme. A computerized database system is a crucial requirement to receive litigable and structured data that is easy to search and trace healthcare environment opportunities.

 

 

 

 

 

 

 

 

 

References

Bushman, S. (2018). Three Steps for Success with Clinical Order Sets. Retrieved from https://www.optimumhit.com/insights/blog/ehr-implementation/3-steps-success-clinical-order-sets

Creasey, T.(2018). What is change management? Retrieved from http://www.howtochangemanagement.com/p/what-is-change-management.html

DeNisco, S. M., & Barker, A. M. (2015).Advanced Practice Nursing (3rd ed.). Burlington, MA: Jones & Bartlett Publishers.

Health IT.(2019). Health IT Legislation | HealthIT.gov. Retrieved from https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation

Hodgkins, M. (2015, March 29). Electronic Health Record (EHR) Implementation. Retrieved from https://edhub.ama-assn.org/steps-forward/module/2702512

Kushan, D. (2017, December 4). How to Track and Measure Success During an EHR System Transition. Retrieved from https://www.healthcareis.com/blog/how-to-track-and-measure-success-during-a-transition

Mind Tools Content Team.(2019). Kotter’s 8-step change model. Retrieved from https://www.mindtools.com/pages/article/newPPM_82.htm

Rupp, S. (2014, November 14). How Nurses Are Using Health Informatics to Improve Patient Care. Retrieved from https://electronichealthreporter.com/nurses-using-health-informatics-improve-patient-care/

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. Cureus11(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 Open1(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 Journal22(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 Symposium2020, 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 Care34(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 & Practice6(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