NUR 514 Benchmark – Electronic Health Record Implementation
Description:
One way informatics can be especially valuable is in capturing data to inspire improvements and quality change in practice. The Agency for Healthcare Research and Quality (AHRQ) collects data related to adverse events and safety concerns. If you are working within a practice setting to implement a new electronic health record (EHR) system, this is just one of the many considerations your team would need to plan for during the rollout process.
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In a paper of 1,500-1,750 words, discuss the following:
- Consider an opportunity for tracking care improvement. What key information would be needed in the database? Example: Time lapse from medication order documented in the EHR to delivery of medication to the patient for the cardiology service.
2. Describe the role informatics plays in the ability to capture this data. What type of project management strategies and methodologies can be implemented to support informatics initiatives to help improve quality within the clinical practice?
The Role of Health Informatics in Data Collection and Management
The importance of information in patient care cannot be overstated, and the field of health informatics has made significant strides in recent years, focusing on the acquisition, storage, and utilization of data within the healthcare sector, with a strong emphasis on technology. Health informatics plays a crucial role in capturing essential data needed for assessing fall risk, and it achieves this by gathering and overseeing data from diverse sources, including patient tracking devices, electronic medical records, and fall assessment tools (Estiri et al., 2018).
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Health informatics facilitates the seamless transfer of data systems, promoting information sharing across different healthcare units and organizations. Furthermore, it excels in capturing an array of data, encompassing all aspects of patient encounters, such as medications ordered, diagnoses made, and diagnostic tests performed. This process involves collecting data from various sources, often presented in different formats, and transforming it into a unified format compatible with the Electronic Health Record (EHR) database.
Project Management Strategies in Health Informatics
Project management strategies play a pivotal role in the realm of health informatics, guiding project managers to address a myriad of challenges and ensuring that all stakeholders have a clear understanding of the objectives of an informatics initiative or project. Effective strategies for promoting successful informatics initiatives include the early definition of project goals and maintaining adaptability throughout the project’s lifecycle.
Informatics project leaders should emphasize the importance of defining the initiative’s goals right from the outset while remaining open to adjustments as needed. Clear and frequent communication is essential to keep the project team informed about the project’s scope, expectations, and any proposed changes (Naseer et al., 2022). Additionally, a deep understanding of the informatics initiative is crucial for the project manager, as it guides resource allocation and provides a realistic perspective on the project’s timeline.
Encouraging teamwork among project members, actively managing project risks, and seeking regular feedback from the team are also vital components of successful informatics initiatives. By implementing these strategies, health informatics project managers can enhance the chances of achieving their project’s goals and driving positive outcomes in healthcare data management and utilization.
3. Discuss which systems and staff members would need to be involved in the design and implementation process. What is the role of the advanced registered nurse in promoting evidence-based practice and leading quality and performance improvement initiatives within this setting?
- Outline strategies for implementing the new EHR proposal. Consider communication changes, transitioning to the new EHR, and managing resources (human, fiscal, and health care resources).
5. Discuss what professional, ethical, and regulatory standards must be incorporated into the design and implementation of the system.
6. Describe the measures and steps you would take to evaluate the success of the EHR implementation from a staff, setting, and patient perspective to measure effectiveness and ensure continuous quality improvement in practice?
7. Explain what leadership skills and theories would be needed to facilitate collaboration with the interprofessional team and provide evidence-based, patient-centered care?
You are required to cite five to 10 sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.
Complete the “APA Writing Checklist” to ensure that your paper adheres to APA style and formatting criteria and general guidelines for academic writing. Include the completed checklist as an appendix at the end of your paper.
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Enhancing Patient Care through Health Informatics and Electronic Health Records (EHRs) Implementation
Health informatics stands as a powerful tool in elevating the quality of patient care and ultimately improving patient outcomes. Providing healthcare providers with comprehensive and accurate information is essential for delivering better medical care. Numerous studies have shown that the implementation of Electronic Health Records (EHRs) plays a pivotal role in enhancing diagnostic capabilities and reducing medical errors, thereby leading to optimal patient outcomes (Hansen et al., 2019). The adoption of EHR systems within healthcare facilities is a critical step in achieving quality care and enhancing patient satisfaction. The benefits of EHRs, as a form of health informatics, are multifaceted. This paper delves into the role of nurse practitioners in different scenarios when it comes to implementing EHR systems in their healthcare facilities.
Leveraging EHR Databases for Identifying Opportunities
A well-designed electronic health record system serves as the foundation for healthcare organizations to develop a functional health information system that improves efficiency. Furthermore, EHRs empower nurse practitioners to identify healthcare opportunities by leveraging the wealth of information available within these systems. Health data encompasses a wide range of information, including patient details, demographics, administrative data, health status, medical history, current medical interventions, and outcomes information (Health IT.gov, 2017). A comprehensive database contains both current and potentially sensitive patient information, which can relate to individuals or entire populations. Clinical and laboratory data are regularly input into these systems to serve as electronic records for patient care.
The sources of information in the database may vary, with data originating from sources such as hospital discharge abstracts, patient-completed questionnaires, insurance claims submissions, employee records, and computerized pharmacy records. Personally identifiable data contains information that can be used to identify individuals. Additionally, electronic medical records (EMRs) contain patient-specific medical information, while EHRs contain a broader spectrum of health-related data.
Nurses and healthcare providers have the opportunity to utilize data from EHRs to make informed decisions, primarily through frameworks like Clinical Decision Support (CDS). CDS offers a range of advantages, including enhanced healthcare quality and outcomes by minimizing errors and adverse effects, cost reduction, increased efficiency, and improved patient satisfaction. The data from EHR systems also enable healthcare practitioners to benefit from Computerized Physician Order Entry (CPOE), which automates the medication ordering process. The incorporation of CPOE, along with CDS and EHRs, enhances patient safety and improves care efficiency.
The Vital Role of Informatics in Data Capture
Health informatics is a field that enables healthcare facilities to collect data and monitor the effects of implementing a new EHR system, ultimately leading to improved performance. The management and utilization of health information through information technology tools help healthcare providers organize health records to enhance patient outcomes. Informatics nurses are tasked with the responsibility of managing, interpreting, and communicating health information, all aimed at improving the quality of care (Yen et al., 2017). The role of informatics in healthcare has been instrumental in achieving better documentation, improving care coordination, and reducing medical errors.
The process of caring for patients begins with the collection of data concerning their medical history, clinical symptoms, allergies, and current medications. Nurses collect this valuable information and record it within the electronic database. Furthermore, healthcare professionals can access and update information in real-time, which significantly reduces medication errors by integrating alerts for potential medical reactions and allergies. The implication here is that informatics nurses play a crucial role in capturing data within the electronic health record system for patients under their care.
Systems and Collaborative Teams in EHR Implementation
The selection and design of an EHR system are influenced by the specific organizational needs, and as such, the organization’s management must create an effective implementation plan. This plan should include input from experts and professionals across various departments within the organization, ensuring that the system aligns with the organization’s goals and requirements. It is essential that the EHR system promotes effective communication between users, particularly between patients and care providers, without hindrance.
A multidisciplinary approach to initiating an EHR system implies that all stakeholders must grasp the new framework and adhere to principles of protection, security, workflow structure, and group collaboration (McCororie, 2019). Effective training on EHR usage is essential to facilitate the transition and ensure that the project benefits patients, nurses, doctors, and other healthcare providers. An organization’s ability to implement an EHR system successfully is contingent upon having a well-rounded team that understands the system and its information governance strategy.
The organization should assemble an implementation team comprised of individuals from different departments. This team will be responsible for designing the system, identifying equipment requirements, sharing information, and streamlining pre-launch procedures. Successful implementation necessitates a skilled and knowledgeable team, with each member bringing their expertise to the table. Within this team, key roles include a lead physician who bridges the gap between healthcare professionals and other staff using the system, a project manager responsible for overseeing the entire project and ensuring the achievement of all project deliverables, and nurses who serve as top users of the new system. IT experts within the organization, administrative staff, and physicians will also provide valuable input during the design and implementation process. Collaboration is a vital aspect of successfully implementing the new system, and each of these individuals plays a critical role in the execution of the plan.
Professional, Ethical, and Regulatory Standards in EHR Implementation
The process of designing and implementing an EHR system must adhere to various ethical, professional, and regulatory requirements and standards. Professional standards are established by professional associations and serve as guidelines for nurse practitioners in various healthcare settings. The American Nurses Association, for example, places a strong emphasis on safety and positive patient outcomes when deploying information technologies in healthcare (Balestra, 2017). The association stresses the importance of data accuracy and proficiency during data collection, storage, analysis, and reporting. Ethical principles related to privacy, confidentiality, and security are also crucial considerations. Healthcare providers must design, implement, and evaluate the use of the EHR system within their healthcare settings, ensuring that ethical principles are upheld.
Regulatory requirements are equally important and are enforced by federal legislation such as the Health Information Technology for Economic and Clinical Health Act (HITECH) and the Health Insurance Portability and Accountability Act (HIPAA). Compliance with these regulations is essential for healthcare organizations, as they are obligated to protect patient health data and personal information. Privacy, security, and confidentiality requirements must be upheld to ensure the practical and effective use of electronic health information. HITECH regulations underscore the importance of adhering to HIPAA standards and increase the legal accountability for entities that fail to comply with the specified data usage and security requirements.
Incorporating Order Sets into the New EHR System
In their pursuit of quality care, healthcare organizations are increasingly embracing evidence-based practices. The use of clinical order sets, which are based on evidence-based guidelines and integrated within the EHR system, is instrumental in reducing errors and improving patient outcomes. To achieve effective and up-to-date order sets, the implementation team should incorporate these elements into the system’s design. Therefore, to achieve success in this model, it is essential to gain the support of key stakeholders and ensure provider satisfaction. Clinical order sets should adhere to best practices and organizational standards, which include identifying and selecting data content sources, reviewing content, and maintaining and updating these resources. The team must establish a process for identifying and replacing content that could impact patient safety or the quality of care if it becomes outdated.
Effective Communication of Changes
The management
of change necessitates the deployment of principles, techniques, and strategies that facilitate acceptance of the transition and improve overall implementation. Kotter’s change model provides a comprehensive framework that the team can use to instill leadership and momentum for change. Different healthcare providers may react differently to the changes introduced within the organization. Some may readily accept these changes, while others may require time to adapt. It is, therefore, crucial to communicate these changes effectively by outlining how the team plans to roll out the EHR system. The team can employ Kotter’s 8-Step Model to communicate changes, which involves creating a sense of urgency for the transformation, forming a powerful coalition, and developing a vision for the changes. Subsequently, the team should communicate this vision, remove any obstacles, and create short-term wins while building on the changes (McCororie et al., 2019). Ultimately, the changes should become an integral part of the organizational culture. The team can use various communication channels, such as banners, posters, flyers, and emails, to convey the changes to individual practitioners.
Evaluating EHR Implementation from Multiple Perspectives
Before the project’s implementation, it is essential to define a set of parameters that will determine the project’s success. Kotter’s 8-Step Model for change provides guidelines for identifying milestones at various stages of the implementation process. Short-term achievements and milestones are established as part of the initial plan before implementation. For instance, the team can set milestones and goals, such as assessing the readiness of stakeholders for the transition and planning the launch of the EHR system based on this assessment and the achievement of meaningful utilization. Thorough preparation at the outset is critical for the successful implementation of the EHR system.
Leadership Skills and Theories for Effective Collaboration
The implementation of an EHR system is a complex endeavor fraught with significant challenges. Therefore, practical leadership skills are essential for ensuring the successful execution of the project. Leadership skills enhance the ability of the lead physician and the team to secure buy-in from users and other stakeholders. These essential skills include effective communication, critical thinking, problem-solving techniques, and project management skills.
Effective communication is crucial, as the team and management must engage employees and other stakeholders, such as patients, to emphasize the benefits of the system. The successful design and implementation of the EHR system require active participation from staff with diverse expertise, perspectives, and experiences. Consequently, communication skills are a critical aspect of the overall success of the project. The team and its leadership also require effective project management and technical skills to facilitate understanding and the delivery of expected outcomes.
Transformative and contingency leadership theories are highly relevant for the design and implementation of the EHR system within the healthcare facility. Transformational leadership ensures that stakeholders collaborate to achieve a common goal. Leaders must motivate, inspire, and stimulate all providers to embrace this innovative way of interacting with patients. The situational leadership model involves making decisions based on the specific circumstances and encouraging effective participation among all stakeholders. These theories emphasize nurturing subordinates and providing guidance tailored to the situation.
In Conclusion
The implementation of an EHR system is a critical step toward improving the quality of care and unlocking various opportunities for providers, particularly through the use of CDSs and CPOEs. Healthcare leaders should embrace EHR systems to enhance efficiency, quality of care, and the benefits of health information technologies. An integrative approach is essential for implementing an EHR system, with the involvement of all stakeholders in the planning process. Most importantly, leaders overseeing EHR implementation must demonstrate effective leadership styles and possess the relevant skills to achieve the project’s objectives.
NUR 514 Benchmark – Electronic Health Record Implementation References
Aldosari, B. (2017). Causes of EHR projects stalling or failing: A study of EHR projects in Saudi Arabia. Computers in biology and medicine, 91, 372-381. DOI: 10.1016/j.compbiomed.2017.10.032
Balestra, L. M. (2017). Electronic Health Records: Patient Care and Ethical and Legal Implications for Nurse Practitioners. The Journal for Nurse Practitioners. Vol 13(2), 105-111. https://doi.org/10.1016/j.nurpra.2016.09.010
Bjarnadottir, R. I., Herzig, C. T., Travers, J. L., Castle, N. G., & Stone, P. W. (2017). Implementation of electronic health records in US nursing homes. Computers, informatics, nursing: CIN, 35(8), 417. Computer Information in Nursing, 35(8):417-424. DOI: 10.1097/CIN.0000000000000344
Hansen, M. B., Nørup, I., Elmholdt, K. T., Kidholm, K., Nøhr, C., & Schmidt, T. (2019, November). Managing Change of EHR Systems. In SHI 2019. Proceedings of the 17th Scandinavian Conference on Health Informatics, November 12-13, 2019, Oslo, Norway (No. 161, pp. 104-107). Linköping University Electronic Press. https://ep.liu.se/ecp/161/018/ecp19161018.pdf
Health IT.gov (2017). Improved Patient Care Using EHRs. Retrieved from https://www.healthit.gov/topic/health-it-basics/improved-patient-care-using-ehrs
Laukka, E., Huhtakangas, M., Heponiemi, T. & Kanste, O. (2020). Review: Identifying the Roles of Healthcare Leaders in HIT Implementation: A Scoping Review of the Quantitative and Qualitative Evidence. International Journal of Environment Research and Public Health, 17(2865). doi:10.3390/ijerph17082865
McCrory, C., Benn, J., Johnson, O. A. & Scantlebury, A. (2019). Staff expectations for the implementation of an electronic health record system: a qualitative study using normalization process theory. BMC Medical Informatics and Decision Making, 19 (222). https://doi.org/10.1186/s12911-019-0952-3
Yen, P. Y., McAlearney, A. S., Sieck, C. J., Hefner, J. L., & Huerta, T. R. (2017). Health information technology (HIT) adaptation: refocusing on the journey to successful HIT implementation. JMIR medical informatics, 5(3), e28. DOI: 10.2196/misinform.7476
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