Electronic Health Record implementation is a process that involves many steps and has an impact on all members of the staff. Just like any other new process, implementation of EHR involves a learning process and needs a solid plan that would save hours of stress for healthcare practitioners and patients. The implementation success of Electronic Health Record is measured by its level of quality improvement of patient care ease of work and collaboration between healthcare professionals. Even though Electronic Health Record increase healthcare access, decreases cost, and improves quality of care, sharing of patients’ health records causes ethical issues to confront healthcare personnel (Burton-Jones & Volkoff, 2017). As a result, patients may conceal some of the vital information needed for their treatment because of fear of their safety and confidentiality. Therefore, Electronic Health implication requires the formulation of policies that will safeguard patient confidentiality.
What would key information be needed in the database that would allow you to track opportunities for care improvement?
Tracking care improvement in electronic health records requires proper information management, patient encounters, patient communication, the appointment process, and medication management, with regards to information about appointment process, using Electronic Health Record to track periods between patient appointment and availability of appointment to identify potential inefficiencies in scheduling in a health facility (CRICO Strategies, 2017). Discovering the inefficiency using Electronic Health Record can help quality improvement.
Besides, information about patient encounters in Electronic Health Record can help in improving care delivery. Electronic Health Record documents reasons for visiting or chief complaints and generate reports that identify the trend of communicable diseases. Once the trends are identified, registered nurses are free to use the information to manage different aspects of their practice. In addition, Electronic Health Record documents problem lists for patients and enforces appropriate review list documentation of changes in patients’ health status and acknowledgment of the physician. Along with that, Electronic Health Records should have a method of storing patient and family health history (Lambooij et al., 2017). It is possible for the system to use the information entered into patient or family history to generate alerts and reminders of patient health to initiate the creation of a more comprehensive approach to patient care and develop preventive screening. Besides, having patient education information in the Electronic Health Record can help a registered nurse to determine the appropriate educational materials to give their patients. As a result, the quality of healthcare delivery is improved.
Moreover, information about medication management in Electronic Health Record is key in the improvement of care quality. The use of report function in Electronic Health Record can help in the identification of redundancies and gaps in the medication reconciliation process of nursing practitioners. Besides, Electronic Health Record can provide an avenue through which medication reconciliation is made (CRICO Strategies, 2017). As a result, the availability of medication information, e-prescribing, and prescription data in Electronic Health Record can facilitate the improvement of quality of service delivery.
What role does informatics play in the ability to capture this data?
In the capturing of patient data, Electronic Health Record plays different roles such as storage, processing, and presentation of data. Unlike manual or paper record-keeping, storage of information is safer, processing of data is faster, and the presentation of information is easier in Electronic Health Record. Patient data in Electronic Health Record is available in just a click but in manual record-keeping, it involves searching from cabinets and shelves to obtain the required file (Rochefort et al., 2017). Additionally, Electronic Health Record can be used to reconcile patient information and treatment records easily.
Which systems and staff members would need to be involved in the design and implementation process and team?
When implementing EHR, there is a need for a strong team to aid in the process to make it as smooth as possible. The team can comprise of the nurses, physicians, administrative staff, as well as medical assistants. The members of the team will offer help by education colleagues on EHR skills besides serving as messengers to the team implementing the process to identify potential challenges during the implementation process. When building a team, there are three essential roles that one must consider: a project manager, a lead physician, and a lead superuser.
In this case, the manager of the project is the center of contact between EHR staff and vendor. The position helps everybody to keep the focus on implementation timelines, tracking progress, and dealing with issues of the users.
The lead physician guides the organization through implementation of the EHR, thus, serves as a link between the technical staff and the frontline system users. A tech-savvy physician can assume this position by welcoming a new process as a lead physician.
The in-house EHR resident expert is the lead superuser. The lead superuser has a few duties like developing workflows and creating a template. The position could also be given other responsibilities, like creating standard operating procedures that address challenges users face while using the system.
What professional, ethical, and regulatory standards must be incorporated into the design and implementation of the EHR system?
Information regarding the illness of a patient should not be released to the public unless the patient permits or the law allows it. In some instances, the patient might not be in a position to decide whether to permit the release of information or not to because of mental incapacity or age. In this case, the decision is left in the hands of the legal guardian or the legal representative of the patient (Higgins et al., 2015). Information released based on clinical interaction is perceived as confidential and should be protected. However, information released regarding a group is not under this category since it is impossible to ascertain the identity of a particular patient. An example of such related information is releasing to the public the number of patient suffering from breast carcinoma.
Insurance companies, health care institutions, and other related institutions will be permitted to access the data only if functions of EHRs are maintained. When preserving confidentiality, only authorized people are allowed to access the information, and the first step towards achieving this is by authorizing users who will have access to the information (Lambooij et al., 2017). The administrator first identifies the users before determining the level of shared information and assigning usernames and passwords (Higgins et al., 2015). Moreover, the users are made aware that they will be responsible for the use and misuse of the shared information. However, they are not restricted from the information they require to perform their responsibility. The privileges assigned to users is a crucial aspect of medical record security.
Despite all the controls against accessing health information, it does not adequately protect confidentiality; thus, the need for additional security measures like security policies and strong privacy to ensure maximum confidentiality (DeVoe et al., 2018). The staff and all providers should also be informed and understand it is also their responsibility to protect and ensure privacy. Privacy policies and confidentiality apply to and auditing activities (including report generation) and all QI.
How would the EHR team ensure that all order sets are part of the new record?
To ensure that all data sets are part of the new records, the EHR team needs first to identify the necessary order sets. Review of available evidence through a “straw model” should be developed after the identification of procedure or conditions as a target for standardized order set (Alsyouf & Ishak, 2018). In addition, physicians need to conduct a series of meetings to ensure that their contribution to the development of the system caters for all order sets. Moreover, the team should include representatives from a minimum of each a pharmacist, BHCS hospital, a relevant BHCS physician champion, and a nursing representative.
How would you communicate the changes, including any transition plan?
After analyzing the audit data, the results are communicated in a positive way to the individuals present in practice. The communication process can be in done in different forms (Vitari & Ologeanu-Taddei, 2018). For example, providing personal results during a periodic performance review or presenting aggregate results in a meeting with all the staff.
What measures and steps would you take to evaluate the success of the EHR implementation from a staff, setting, and patient perspective?
After analyzing and communicating the audit results, the step that follows is the development and implementation of a corrective action plan according to the way the root of the problem is understood. The process involves the identification of best practices for comparing the data. Planning and implementation of corrective actions call for commitment and involvement from the entire team (Klapman, Sher, & Adler-Milstein, 2018). Implementation of the corrective actions does not mark the end of the audit since there is a need to ensure consistent application of the changes and whether improvement occurs; thus, the importance of auditing after implementation.
What leadership skills and theories would facilitate collaboration with the interprofessional team and provide evidence-based, patient-centered care?
Interprofessional collaboration and improved care coordination are one of the important areas of concern and approaches when it comes to facilitating patient-centered care and evidence-based practice. However, changes might be a requirement for effective implementation of care coordination that associates with interprofessional collaboration. For the sake of leadership skills, interprofessional collaboration helps team leaders and members and sometimes patients to reach an agreement about important decisions (Jones & Delany, 2014). The likelihood demonstrates the importance of support from the IPC and implementation at various levels. It calls for the public, professional organizations, and policymakers for the IPC to improve the safety of the patient.
CRICO Strategies. (2017, September 12). CBS educational webinar: EHR-related risks.
Higgins, T. C., Crosson, J., Peikes, D., McNellis, R., Genevro, J., & Meyers, D. (2015, March). Using health information technology to support quality improvement in primary care (AHRQ Publication No. 15-0031-EF). Rockville, MD: Agency for Healthcare Research and Quality.
Shea, Christopher M, Halladay, Jacqueline R, Reed, David, & Daaleman, Timothy P. (2012). Integrating a health-related-quality-of-life module within electronic health records: a comparative case study assessing the value added. (BioMed Central Ltd.) BioMed Central Ltd.
Alsyouf, A., & Ishak, A. K. (2018). Understanding EHRs continuance intention to use from the perspectives of UTAUT: practice environment moderating effect and top management support as predictor variables. (International journal of electronic healthcare.)
Klapman, S., Sher, E., & Adler-Milstein, J. (2018). A snapshot of health information exchange across five nations: an investigation of frontline clinician experiences in emergency care. (Journal of the American Medical Informatics Association.)
Vitari, C., & Ologeanu-Taddei, R. (March 21, 2018). The intention to use an electronic health record and its antecedents among three different categories of clinical staff. Bmc Health Services Research, 18, 1, 1-9.
DeVoe, J. E., Hoopes, M., Nelson, C. A., Cohen, D. J., Sumic, A., Hall, J., Angier, H., … Gold, R. (May 10, 2018). Electronic health record tools to assist with children’s insurance coverage: a mixed methods study. Bmc Health Services Research, 18, 1, 1-13.
Lambooij, M.S. (Mattijs), Drewes, H.W. (Hanneke W.), & Koster, F. (Ferry). (2017). Use of electronic medical records and quality of patient data: different reaction patterns of doctors and nurses to the hospital organization. (B M C Medical Informatics and Decision Making vol. 17 no. 1, pp. 1-11.)
Burton-Jones, A., & Volkoff, O. (September 01, 2017). How Can We Develop Contextualized Theories of Effective Use? A Demonstration in the Context of Community-Care Electronic Health Records. Information Systems Research, 28, 3, 468-489.
Rochefort, C. M., Buckeridge, D. L., Tanguay, A., Biron, A., D’Aragon, F., Wang, S., Gallix, B., … Lefebvre, P. (February 16, 2017). Accuracy and generalizability of using automated methods for identifying adverse events from electronic health record data: a validation study protocol. Bmc Health Services Research, 17, 1, 1-9.
Jones, G., & Delany, T. (2014). What does collaborative practice mean within mental healthcare? A qualitative study exploring understandings and proposing a definition. Journal of Research in Interpersonal Practice and Education, 3(3). Retrieved from http://www.jripe.org/index.php/journal/article/view/154
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