Electronic Health Records Essay

In a paper of 1,250-1,500 words, address the following questions related to the advanced registered nurse\’s role during this type of scenario: What key information would be needed in the database that would allow you to track opportunities for care improvement? What role does informatics play in the ability to capture this data? Which systems and staff members would need to be involved in the design and implementation process and team? What professional, ethical, and regulatory standards must be incorporated into the design and implementation of the system? How would the EHR team ensure that all order sets are part of the new record? How would you communicate the changes, including any kind of transition plan? What measures and steps would you take to evaluate the success of the EHR implementation from a staff, setting, and patient perspective? What leadership skills and theories would facilitate collaboration with the interprofessional team and provide evidence-based, patient-centered care? Electronic Health Records Essay

Benchmark – Electronic Health Record Implementation

Introduction

Implementing an electronic health record system in healthcare organizations involves a combination of organizational and technical aspects such as human skills, technology, finances, resources, organizational leadership, and culture (Muinga et al., 2018). It is important to ensure the involvement of all pertinent stakeholders when implementing an electronic health record (EHR) system. This assignment discusses the information, the role of informatics, and stakeholders involved in the implementation of an EHR system (Muinga et al., 2018). The paper will also discuss the importance of interprofessional collaboration and effective leadership when implementing the system, as well as the relevant regulatory, professional, and ethical standards necessary to facilitate safe and quality healthcare.

Key Information in Database, Informatics, and the Relevant Staff Members

The key information in the database includes the patient’s demographics, medical history, medications, diagnoses, treatment plans, test and laboratory results, allergies, and immunization updates (Kruse et al., 2018). The information allows healthcare providers to access information and evidence-based tools useful in making decisions regarding the patient’s care. To collect the structured and litigable information accessible easily, a computer system database will be necessary. An EHR system is useful in facilitating access to patient information, as well as allows easy access to the necessary data, and facilitate mining of the relevant data (Kruse et al., 2018). An EHR system, therefore, leads to improved patient care as well as patient safety by facilitating care coordination, identifying risk factors such as falls, and preventing medication errors.

The team that should be involved in the implementation of the EHR system encompass the EHR team leader, nurse informatics, physician, nurse lead, EHR constructor, informational technology experts, laboratory staff, EHR constructor, as well as workflow redesign lead. The IT department will collaborate with the informatics staff to select the EHR system and the appropriate devices (Atasoy et al., 2019). The frontline staff and clinical managers will examine the suitability of the point of care equipment as well as the medication delivery charts provided by vendors.

Health informatics is useful for organizing health record records and managing the patient information to improve care and health outcomes (Atasoy et al., 2019). Nurse informatics therefore manages, interprets, and communicates the health information in order to improve care delivery and quality of care. Informatics enhances care by improving documentation and management of patient information, reducing medical and medication errors, as well as in improving coordination of care. Electronic Health Records Essay

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Integration of the Regulatory, Ethical and Professional Standards

The EHR system should be developed as per the relevant regulatory, ethical, and professional requirements (Evans, 2016). For example, an interface should be integrated to ensure the patient data is accessed by the authorized parties to ensure the privacy and confidentiality of the patient data. The patient data should be accessed as per the pre-established role-based privileges. The user is first identified, as well as the level and the data that should be shared, and the usernames, passwords, and PINs are allocated. Users should be informed about their role in protecting patient information. The system should install strong security measures and implement privacy policies that support adequate protection of patient information (Evans, 2016).

The design of an EHR system should be as per the guidelines of the National Institute of Standards and Technology (NIST). Legislations such as the HITECH and HIPAA should be adhered to during the design and implementation of the EHR system. The integrity, confidentiality, and availability of the information should be addressed when designing the system.  For integrity, the patient data collected and stored in the EHR system should be accurate and should not be tampered with during storage. The design of the EHR system should protect the manipulation of the data (Ozair et al., 2015). Moreover, the security and privacy policies should protect any unauthorized access to the patient data.

Setting Order Sets as Part of the New Record

The initial step involves securing the administration support and organizational buy-in. Developing an order set is an organizational initiative that needs support from the management, and should be developed stepwise (Robinson & Kersey, 2018). Accordingly, the design of the order sets for the system should be at the organizational level. Secondly, prior to developing the EHR system, the current workflow procedures should be established and identify any bottleneck that should be eradicated. The framework of the EHR system should encompass a single formulary, order catalog, laboratory system, consolidated nutritional systems, protocols, intranet for documents, as well as procedures linked to the components of the order sets through URLs, and a system for tracking the progress of the order sets. All members of the interdisciplinary team will be involved when designing and developing the order sets to ensure every member provides input (Robinson & Kersey, 2018).

The order sets within the system ought to be short while the common sub-sets need to be chosen. Usage of reminders and notes needs to be minimized while systematized libraries for the order set components need to be developed. All stakeholders should be trained regarding the EHR system and the order sets the order to equip them with the necessary knowledge and skills to operate the system (Robinson & Kersey, 2018).

Communicating Changes

A communication plan to guide communication for all stakeholders will be developed. All departmental heads will communicate the changes to the staff in their respective departments (Alkureishi et al., 2018). The frontline staff members will be trained to facilitate a successful transition. The trained staff members will train their peers after the launch of the EHR system. The management in the organization will be advised about the importance of minimizing the patient load during the initial period of the EHR system, until when the staff has become competent in operating the implemented ordering system (Alkureishi et al., 2018). Electronic Health Records Essay

Evaluating the Success EHR System

Evaluation of the successful implementation of the EHR system involves examining the competency and efficiency of the staff members to utilize the EHR system. Secondly, the ability of the implemented system to reduce waiting patient time decreased rate of medication errors, improved care coordination, and lowered organizational costs will be an indication of the system’s success (Aguirre et al., 2019). In addition, improved patient outcomes and improved patient safety after the implementation of the EHR system will also indicate success for the system. A patient satisfaction survey will be issued to patients visiting the healthcare facility to collect their perspectives about the change and also to examine the level of patient satisfaction (Nguyen et al., 2015). Improved patient satisfaction and their positive reviews about patient care will indicate the successful implementation of the EHR system.

Leadership Skills and Theories

The transformational leadership style will guide the implementation of the EHR system to inspire and motivate the team and staff members to support the EHR system. The transformational leadership style will be used by the team steering the EHR system to model, support, and show the organizational members how the system should be used and to model the suitable steps to ensure successful implementation of the EHR system (Sfantou et al., 2017). Leadership skills like teamwork and communication skills will be essential when implementing the system.

Theories that will guide the implementation of the EHR system include social cognitive theory and the diffusion of the innovation theory. The social cognitive theory will be used to ensure all the relevant stakeholders under the independent and interdependent nature and importance of collaboration from all relevant stakeholders during the development of an interprofessional model. On the other hand, the diffuse theory will be useful in providing a framework that ensures the change is implemented, accepted, and adopted successfully in the organization (Mohammadi et al., 2018).

Conclusion

All the relevant stakeholders will be actively involved when implementing the EHR system. The system will be designed as per the appropriate ethical, professional, and regulatory standards when the privacy, security, confidentiality, and integrity of the patient information will be ensured. Social cognitive theory, the diffusion of innovation theory, and the transformational leadership style will be used to guide and ensure the successful execution of the EHR system.  Electronic Health Records Essay

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

Alkureishi, M. A., Lee, W. W., Webb, S., & Arora, V. (2018). Integrating Patient-Centered Electronic Health Record Communication Training into Resident Onboarding: Curriculum Development and Post-Implementation Survey Among Housestaff. JMIR medical education, 4(1), e1. https://doi.org/10.2196/mededu.8976.

Atasoy, H., Greenwood, B. N., & McCullough, J. S. (2019). The digitization of patient care: A review of the effects of electronic health records on health care quality and utilization. Annual review of public health, 40, 487-500.

Evans R. S. (2016). Electronic Health Records: Then, Now, and in the Future. Yearbook of medical informatics, Suppl 1(Suppl 1), S48–S61. https://doi.org/10.15265/IYS-2016-s006

Kruse, C. S., Stein, A., Thomas, H., & Kaur, H. (2018). The use of electronic health records to support population health: a systematic review of the literature. Journal of medical systems, 42(11), 214.

Mohammadi, M. M., Poursaberi, R., & Salahshoor, M. R. (2018). Evaluating the adoption of evidence-based practice using Rogers’s diffusion of innovation theory: a model testing study. Health promotion perspectives, 8(1), 25–32. https://doi.org/10.15171/hpp.2018.03.

Muinga, N., Magare, S., Monda, J., Kamau, O., Houston, S., Fraser, H., Powell, J., English, M., & Paton, C. (2018). Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study. JMIR medical informatics, 6(2), e22. https://doi.org/10.2196/medinform.8403

Nguyen, L., Bellucci, E., & Nguyen, L. T. (2015). Electronic health records implementation: an evaluation of information system impact and contingency factors. International journal of medical informatics, 83(11), 779-796.

Ozair, F. F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical issues in electronic health records: A general overview. Perspectives in clinical research, 6(2), 73–76. https://doi.org/10.4103/2229-3485.153997.

Robinson, K. E., & Kersey, J. A. (2018). Novel electronic health record (EHR) education intervention in large healthcare organizations improves quality, efficiency, time, and impact on burnout. Medicine, 97(38), e12319.

Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Importance of Leadership Style towards Quality of Care Measures in Healthcare Settings: A Systematic Review. Healthcare (Basel, Switzerland), 5(4), 73. https://doi.org/10.3390/healthcare5040073.

Electronic Health Records Essay