NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper
NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper
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).
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 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).
“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).
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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).
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.
NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper 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/
Quality improvement in patient care is one of the ways in which healthcare organizations achieve their desired goals and objectives. The improvement in quality of care is achievable using methods such as the utilization of electronic health records (EHR) to optimize on care outcomes. Electronic health records enable health organizations to achieve their desired efficiency, quality and safety in the use of health technologies in patient care. They use it in data collection, organization, analysis, and retrieval for easy decision making on the care needs by the patients. Therefore, the purpose of this paper is to explore the opportunities that exist for tracking care information with the adoption of a new electronic health records system. It also focuses on the roles of informatics in the new system as well as those of the advanced registered nurse in the use of health information systems and the leadership styles and approaches needed to facilitate the success of the process.
Key Information in the Database
The newly adopted system should enable opportunities for tracking improvements in the organization. The database should therefore contain a number of information that would be used for tracking improvements. One of the information relates to those for tracking patient response to treatment. The database should be able to capture the problems of patients at the time of contact with the provider, the adopted interventions, and assessment of their effectiveness in facilitating health, wellbeing and recovery. The other information is the demographics of the patient. The database should be able to capture the key demographic data that relates to health. The information will be used for tracking trends of health problems in the population. An additional information is progress notes, diagnostic, and laboratory information. The information will be used for evaluating the need for specific interventions and their effectiveness in facilitating the effective management of the health problem. The other type of information relates to indicators of safety and quality in the organization (Hussey & Kennedy, 2021). The database should capture information such as rates of adverse events in the organization to enable the determination of safety and quality of care given to patients in the institution.
Role of Informatics
Informatics plays a critical role in the ability to capture the above information. Firstly, informatics comprises clinical tools as well as applications that facilitates the capturing of health-related data in the electronic databases. The capture data is important for use in advancing the medical care that patients receive. The informatics applications and tools also organize the data obtained from different sources of care in the organization (Sipes, 2019). It organizes the data into forms such as the electronic medical records and devices for tracking health. The organization of data seeks to ensure efficiency in use in making clinical decisions. Informatics also enables easy retrieval of information by the healthcare providers. Accordingly, healthcare providers have enhanced opportunities to access stored data whenever needed to facilitate decision-making. Besides capturing, storing, and retrieval, informatics has security systems embedded in them to ensure data integrity (Barrett, 2018). The systems have advanced levels of security that eliminates any potential access of the private and confidential data by unauthorized parties.
Systems and Staff Members
The successful implementation of the new EHR system will require the use of a number of systems as well as the involvement of different staff members. There is a need for systems such as billing, documentation, and reimbursement systems. There is also the need for systems to facilitate e-prescribing, telehealth, and report generation. The reimbursement and billing system will enhance the efficiency of paying for healthcare services and making insurance claims. The e-prescribing will be used to order electronic prescriptions for patients. The documentation system will be used for keeping the health records of the patients. The report generation system will be used in developing summaries of healthcare services given and their effectiveness in delivering the expected institutional outcomes (Hussey & Kennedy, 2021).
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The staff that will be involved in the project will be varied. They will include nurses, physicians, IT officer, system developer, and project manager. Nurses and physicians will be the direct adopters of the new electronic health records system. Their involvement in the implementation entails ensuring that the system is user-friendly and facilitates their needs in the provision of patient care. The IT officer will provide the technical support needed for the efficient use of the new system. The system developer will train the staffs on the use of the new system. The developer will also address any technical issues that may be experienced with the use of the system in patient care. The project manager will oversee the whole process of implementation (Hussey & Kennedy, 2021). The manager will ensure efficient use of resources to achieve optimum outcomes with the newly adopted system.
The advanced registered nurse will play a number of roles in promoting-evidence based practice and leading quality and performance improvement initiatives within the setting. Firstly, the nurse will ensure the use of evidence-based interventions in the use implementation of the new system. The nurse will use their knowledge and skills gained in nursing informatics to influence the utilization of best interventions in the implementation process. The advanced registered nurse will also act as coach and mentor in the use of the new system (Cowie et al., 2017). They will promote competency development in the users of the new system for the realization of the desired goals in its use in the organization.
Strategies for Implementing the New EHR Proposal
The successful implementation of the new EHR proposal will require the consideration of a number of strategies. One of them will be communication. The users of the new system will be informed about the intended changes in EHR system. Communication will be achieved through internal memos in the organization. The second strategy will be training. The users will be trained to ensure they are competent in using the new system. Training will also minimize the risk of resistance to change from the users (Hussey & Kennedy, 2021). The implementation process will also be systematic. Accordingly, new order sets related to the system will be introduced gradually for use in the organization, as the old system is replaced. A plan for human resource management during the implementation will also be developed. The plan will guide the use of the allocated resources as well as the evaluation of whether the set goals and objectives of the new system are being achieved (Barrett, 2018). Regular assessments will be done to ensure that continuous quality improvement is achieved in system implementation process.
Professional, Ethical and Regulatory Standards
Professional, ethical, and regulatory standards should be incorporated into the implementation of the new electronic health records system. The professional regulatory standards that must be considered include undertaking risk analysis of the system as well as acquiring HIPAA compliance certificate. A risk analysis will enable the identification of institutional weaknesses that should be addressed for the efficient use of the new system (Rathert et al., 2019). The organization also has to obtain HIPAA certificate to ensure that its practices align with those of the regulation as well as promoting the safe use of information technologies in healthcare. The institution should abide with the regulatory provisions of HIPAA and HITECH regulations by performing regular assessment of the systems and undertaking the necessary improvements. The institution should also train its providers on a regular basis to ensure the staffs have the needed competencies in ensuring safe use of the new system. Ethical standards must also be adhered to in the adoption of the new system. The institution and its staffs must ensure the protection of data privacy and confidentiality. They ensure the safe use of health information system by eliminating unintended access and use of the patient data. The healthcare providers must also demonstrate their compliance with HITECH and HIPAA regulations in all the processes of the new system use such as assessment, planning, implementation, monitoring, and evaluation (Hussey & Kennedy, 2021).
The success of the new EHR system will be evaluated from staff, setting, and patient perspectives to determine the effectiveness of the system as well as ensure continuous quality improvement. Surveys will be administered to the staffs to obtain information about their experiences with the new system. The surveys will provide information about the success of the new system and the things that should be improved to facilitate its optimum functioning. Questionnaires and surveys will also be administered to the patients. Patients will provide crucial information about their subjective experiences with the care given in the organization. They will provide information related to their perceived safety, quality, and efficiency of care they receive in the organization. The evaluation of the new system from the perspective of the setting will focus on safety and quality metrics of care (Sipes, 2019). It will focus on aspects such as timeliness of care, changes in safety and adverse events, and cost-efficiency and effectiveness of its operations.
Leadership Skills and Theories
One of the leadership skills that would be needed to facilitate collaboration with the interprofessional team and provide evidence-based, patient-centered care is team building. Team building is needed for effective inter-professional and evidence-based patient-centered care. The healthcare providers should be able to work in teams in assessing, planning, implementing, monitoring, and evaluating the plans of care utilized to address patient needs. The other skill is open communication. Open communication is important to eliminate errors in care, as well as strengthen the effectiveness of the inter-professional interventions utilized to achieve optimum outcomes in patient care (Hassmiller & Pulcini, 2020). The last skill is creativity. The leader should motivate the followers to utilize creative and innovative solutions that are unique to the needs of their patients. Creativity advances the safety, quality, and efficiency of patient care. The leadership theories that may be utilized include transformational, servant, and democratic leadership theories, as they aim at empowering team members take responsibility for the care given to patients (AL-Dossary, 2017).
The newly adopted EHR system should be able to facilitate the tracking of care improvements in the organization. It should also facilitate the efficient management of care across the different levels in the organization. Professional, ethics, and regulatory standards will influence the adoption of the new system. Healthcare providers and institutions should therefore strive to ensure that ethics and regulations that guide the use of health information systems are considered in the implementation process.
NUR 514 Week 8 Assignment Benchmark – Electronic Health Record Implementation Paper References
AL-Dossary, R. N. (2017). Leadership in Nursing. IntechOpen.
Barrett, A. K. (2018). Technological appropriations as workarounds: Integrating electronic health records and adaptive structuration theory research. Information Technology & People, 31(2), 368–387. https://doi.org/10.1108/ITP-01-2016-0023
Cowie, M. R., Blomster, J. I., Curtis, L. H., Duclaux, S., Ford, I., Fritz, F., Goldman, S., Janmohamed, S., Kreuzer, J., Leenay, M., Michel, A., Ong, S., Pell, J. P., Southworth, M. R., Stough, W. G., Thoenes, M., Zannad, F., & Zalewski, A. (2017). Electronic health records to facilitate clinical research. Clinical Research in Cardiology, 106(1), 1–9. https://doi.org/10.1007/s00392-016-1025-6
Hassmiller, S. B., & Pulcini, J. (2020). Advanced Practice Nursing Leadership: A Global Perspective. Springer Nature.
Hussey, P., & Kennedy, M. A. (2021). Introduction to Nursing Informatics. Springer International Publishing.
Rathert, C., Porter, T. H., Mittler, J. N., & Fleig-Palmer, M. (2019). Seven years after Meaningful Use: Physicians’ and nurses’ experiences with electronic health records. Health Care Management Review, 44(1), 30–40. https://doi.org/10.1097/HMR.0000000000000168
Sipes, C. (2019). Application of Nursing Informatics: Competencies, Skills, and Decision-Making. Springer Publishing Company.
The value of the inter-professional collaborative practice is increasingly recognized. Care delivery processes involve numerous interfaces and patient handoffs among multiple healthcare practitioners with varying educational and occupational training levels. Shrader et al. (2016) posit that current communication technologies may provide avenues to improve healthcare team communication and workflow. The versatile nature of technology has demonstrated that healthcare professionals depend on its use. Effective collaboration and communication are vital for any team to achieve inter-professional, patient-centered care. According to Brown-Manhertz (2017), healthcare teams use many diverse electronic methods in the clinical setting to coordinate patient care. These include email, video conferencing, pagers, electronic EHR messaging, smartphone applications, and two-way or group texting options. When used appropriately, electronic communication devices can improve the organization of daily group activities and administrative tasks.
The use of smartphone-based technology has been proposed to improve the delivery of care in healthcare facilities. Smartphones play a key role in keeping interdisciplinary team members connected. Most individuals in the United States have access to and use smartphones to facilitate effective collaboration. Manocha et al. (2020) posit that healthcare teamsvalue using emails when communicating non-urgent issues. However, the phone function’s availability enables clinicians’ access, especially in urgent situations. Besides, smartphone-based technologies support health monitoring, health-related data gathering, and the provision of remote care. This allows nurse leaders, physicians, and patients to build and maintain health and wellness strategies outside a clinical setting. Unfortunately, nurses’ unilateral control of the smartphone communication functionality may contribute to pressures between physicians and nurses, compromising inter-professional relationships (Manocha et al., 2020). To foster and sustain effective inter-professional collaboration, smartphone technology needs to enable physicians to prioritize return calls and minimize workflow disruption. Smartphones must be configured to meet all the work needs of all team members.
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