C791 Advanced Information Management – Electronic Health Record (EHR) Essay
Advanced Information Management C791
Advanced Information Management C791
The Electronic Health Record, also known as EHR is a digital database of both past and current clinical information including everything from demographics to test results and medical conditions (Tan & Payton, 2017). Health information systems have both advantages and disadvantages surrounding their usability, interoperability, scalability and compatibility. They have a direct affect on patient care and documentation and can affect the quality and delivery of nursing care and patient outcomes. Having access to patient records using an EHR allows information to be immediately available to all providers who have access to the EHR – including co-workers in other areas of the same hospital as well as in other hospitals with the same EHR. This can be extremely beneficial to the patient and health care providers alike. Unfortunately, EHRs are very expensive to implement as well as maintain – as they require multiple levels of training as well as periodic upgrades due to changes in healthcare delivery as well as system changes.
Health Information Systems
A1. There are advantages and disadvantages of the EHR. In the area of usability, young nurses may have only been exposed to EHRs, and in fact most or all of their education may have taken place with electronic textbooks, tests and paper submission. For them, using an EHR may be very easy and they will have an advantage over older nurses, like myself, who learned nursing on pen and paper. All of my nursing schoolwork involved writing papers by hand and testing on paper. Advantages for nurses young and old, however, are the systematic charting methods provided by an EHR. Quick templates for charting and check-box documentation on the EHR can provide reminders for the nurse to ensure that all problems that the patient is experiencing are addressed.
A disadvantage can occur when the n nurse uses only the check-boxes and fails to provide to elaborate on issues occurring which are not addressed in the boxes. Without adding a narrative or written progress note in addition to the check boxes, the nurse may not truly tell the patients’ story, allowing for important details to be omitted. In the area of interoperability, one advantage is that if multiple providers use the same EHR, the patients records may be visible by all providers.
For instance, if a patient sees a primary care physician who is aligned with a hospital system, then if the patient is admitted to the hospital he/she is aligned with the notes, diagnoses, lab results and demographics will all be visible by both the office staff and the hospital staff. Additionally, interoperability with lab would ensure that test results would flow into the chart rather than allowing for the chance for human error in entering lab values or times.
A disadvantage would be if the patient sees a primary care physician who uses one type of EHR and presents to a hospital with another type of EHR. Most EHRs are only compatible with like EHRs, so the only way to ensure information from a physician office would not be visible by hospital staff or if one hospital system uses one type of EHR and another hospital system uses another type of EHR, there would be no visibility of information if the patient was transferred from one hospital to another.
As related to scalability, an advantage would occur if the EHR chosen by a hospital is capable of expanding as healthcare regulations change and as the hospital system grows or expands to include additional service lines. A disadvantage would occur if the EHR chosen had limits on the ability to optimize the use to fit the needs of changing healthcare regulations or if it would not allow for expansion or growth throughout the system.
Compatibility of the EHR would be an advantage if the current computer system of the hospital could handle the EHR without purchasing new equipment. When patients’ blood glucose levels are tested, does the information from the glucometer flow directly into the EHR? This would definitely be an advantage. Also it would be advantageous if the EHR had the ability to run on different hardware, as many people have a preference of the system they use.
It would be a disadvantage if the EHR only ran on one system, or was only able to function in one area of the hospital. It would be important to ensure that the EHR had platforms for the Emergency Department, Inpatient, Outpatient, Surgery and Testing areas. If it was not capable of crossing over to any area of the hospital the patient might experience during a stay, it would be a disadvantage.
A2. Patient care and documentation can be positively impacted by implementation of an EHR. Using an EHR provides that all patient information is recorded in the exact same manner on each patient and provides continuity of care between shifts. Reminders for labs, medications, tests, and other areas of patient care can be helpful to ensure that the nurses caring for the patient provide all of the care ordered for the patient during their shift.
Additionally, if the patients chart needs to be reviewed for quality indicators or issues, the care is documented in the same manner and in the same area for each patient. If the patient seeks care from another physician or hospital system that uses the same EHR, then their care has the potential to be more appropriate because their history will be available for physicians, nurses and other caregivers with access, resulting in a higher level of care provided.
A3. The quality and delivery of nursing care and patient outcomes can be positively affected with the implementation of the EHR. Quality reviews can take place in real time – while the patient is still a patient- rather than having to wait for paper documentation to be scanned in to a record. Additionally, with paper documentation, there is no way to mine data to measure quality across a unit or a hospital.
Data mining is the process of using software to discover or establish relationships (Mastrian & McGonigle, 2017). If patient data is entered into an EHR, reports can be run to determine what treatments are being used, if they are effective and if proper documentation is happening among many other things. Patient outcomes can be positively affected because chart audits can happen in real time.
B1. The EHR provides the opportunity to improve efficiency and quality of patient care, resulting in better outcomes (Mastrian & McGonigle, 2017). Patients come to healthcare facilities with hopes to get better. They do not plan to get sicker or to have complications, known as Hospital Acquired Conditions or HACs, resulting from treatments that they receive (or do not receive) during their hospitalization.
In the facility where I work, approximately 3 years ago, a HAC known as Catheter Associated Urinary Tract Infection or CAUTI rates were high, and we set out on a mission to decrease these rates. We tracked and trended the rates of infection and the number of catheter days for each infection, from our EHR for the previous 3 years, and came up with goals for number of catheter days and diagnoses requiring catheterization vs. catheter use for nurse convenience.
Additionally, we looked at where the CAUTIs were occurring (what unit), the age of the patient, what the course of treatment was (did the patient go to surgery or other diagnostic areas) and even drilled down to what nurse(s) and aide(s) cared for the patient. Nurse(s) and tech(s) caring for patients who developed a CAUTI were counseled and education was provided to all newly hired employees. Because of the information we gathered, using the EHR our nurse leadership team created a report to run each day to determine what patients might be at greatest risk for a CAUTI.
The EHR allows for reports to be very in depth and include information such as what patients have catheters and how many days the catheter has been in place. Knowing the longer the catheter is in, the higher the risk of infection, we work as an interdisciplinary team to determine if the patient needs to continue with the catheter or if it could be discontinued. This, along with other actions such as implementing the use of TheraWorx cleaning have caused a significant decrease in the amount of CAUTIs.
In 2015 and 2016, our hospital had seven CAUTIs during each year. In 2018 we had three CAUTIs and year to date in 2019 we have only had two. This is because of reports run and analyzed from the EHR. HAC rates are continually measured using data from the HER to improve patient outcomes. Another way that quality improvement data collected can lead to measurable improvement is by using the EHR to review charts of patients who have had a negative outcome during a hospital stay, such as a fall with injury or a medication error.
In the case of a fall with injury, our quality department will use the EHR to perform a full chart review. Then, they will use the information from the chart review to determine what co-workers were involved in the event, what medications or treatments the patient was receiving, and what the patient was doing at the time of injury. Every patient receives a fall risk assessment at the time of admit, completed in the HER, resulting in a fall risk score which is visible by the bedside nurse and others providing care to ensure the proper precautions are in place.
If the patient experiences a fall, a near miss, or a change in condition, the bedside nurse is prompted to complete a new fall risk assessment in the EHR which will result in a new fall risk score. If the event is what as known as a never event, such as a death as a result of the fall, then this is reportable and the EHR will be useful to both the quality and legal department of the hospital as well as federal or state regulatory agencies or legal counsel who obtain access to the EHR.
B2. There are federal guidelines regarding the privacy of health information for EHRs including the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH) (Mastrian & McGonigle, 2017). Additionally, anyone using an EHR needs to ensure information is secure and network security is managed (Mastrian & McGonigle, 2017).
In the hospital where I work, we have a unit for geriatric psychiatric patients. This is a locked unit with limited access and all patients are considered private. Their names are not visible by all on house census reports or other documents. Only co-workers who have electronic access, granted by their leader, can access the records of these patients. Because it is not practical to assume that everyone a patient on this unit comes into contact with would have this electronic access, a level of security known as “breaking the glass” exists in our EHR.
This allows for anyone to access their record, but in order to do so they have to “break the glass” which requires them to state the reason they need to be in the chart and agree to quality review to ensure they have the right and the access is necessary. This insures the patients in this high security area are kept as private as possible. Data back-up is also necessary. A few years ago, a Mercy Hospital in Joplin, Missouri was completely destroyed by a tornado.
Many patient records were destroyed and while patients were cared for in other facilities in the area, their information was not accessible due to the other hospitals not having compatible EHRs. This data was eventually recoverable, but not in real time. As a result, each Mercy Hospital now has all of its data backed up to a computer system offsite in a database accessible to anyone at any time. The data isn’t just stored on-site, but continually backed up offsite. These measures assure compliance with HIPAA and HITECH.
B3. Patient privacy is protected in many ways in an EHR. In the hospital where I work, a watchdog system is in place to monitor everyone who views a patient’s chart. If at any time, an employee views a patient chart and there is a match of the last name or home address, an alert is sent to the employee’s leader. It is then the leader’s role to investigate the reason the employee viewed the chart.
The EHR system we use is EPIC, and the watchdog system reveals all locations in the chart viewed by the employee. If the employee had a reason to be in the patient’s chart, such as checking in the patient in the Emergency Department, but the only part of the chart viewed by the employee was the check-in screen, then there is no reason for disciplinary action. But if that same employee, responsible for checking in the patient to the Emergency Department went on to view previous visits or lab results, then they have violated HIPAA and are disciplined according to the hospital policy for privacy which aligns with HIPAA.
Patient privacy is additionally protected through the process of granting employees access to the EHR. Each employee’s leader is responsible for requesting access which aligns with their training and job duties. Kitchen employees have no reason to be in a patient’s chart, so they are not trained in the EHR and do not have access. Nurses are only given access to patients on the floor(s) or department(s) where they will be working. This assures employees are not given access to patient’s private information when not required for the completion of their duties.
B4. Organizational efficiency and productivity will improved by adopting an EHR, although there have been few studies of EHRs with very little reported data (Mastrian & McGonigle, 2017). One way that efficiency is improved is standardization of charting using the EHR. Pathways can be built for standard physician orders for patients with specific conditions such as Chronic Obstructive Pulmonary Disease or COPD.
Head to toe assessments are completed by multiple nurses across multiple shifts, but using the EHR, the assessments are completed the same way every time. The same documentation on each patients provides continuity of care for patients across the continuum of care, in addition to providing the ability to view data complied over a whole hospital stay on one screen in the same place every time.
Productivity will be improved because the members of the care team will all be able to document at the bedside while care is being performed. In the case of a patient in cardiac arrest, where multiple members of the care team are providing care simultaneously, EPIC EHR provides a “code narrator” allowing for one point person to document all interventions during the code in real time while the code is happening.
In the absence of an EHR, this documentation would be done by hand and might not be the same way every time or might cause the nurse doing the documentation to chart after the end of the event taking up time that could be used to care for other patients or to continue care on that patient if they survive. Additionally, once the documentation is entered into the EHR in real time, there is no need to scan any documents or information into the chart which provides a streamlined method of recordkeeping.
If patient information is recorded on paper rather than in an EHR, there could be waste as eventually the paper would be scanned into the chart and then shredded to ensure privacy. Efficiency can also be enhanced in the area of human and capital resources. Using an EHR, each time a procedure is performed on a patient, a medication is given or a supply is used, these are recorded in the EHR and automatically charged to the patient account.
This decreases the need for someone to enter charges manually into the system, thereby increasing productivity and decreasing the number of people required for care. In addition to the data listed above, there are many other ways organizational efficiency and productivity will improve with the implementation of an EHR.
Essential Stakeholder Roles for System Implementation
There are multiple layers of leadership required for implementing an EHR within a healthcare system, including but not limited to: Implementation Manager, Physician Champion, Information Technology Lead and SuperUser Lead. The Implementation Manager may be associated with the vendor of the EHR. They are responsible for making sure the project is on schedule, monitoring the work plan, maintaining a list of problems at the hospital or vendor level that need resolution, scheduling events surrounding implementation and may include communicating updates to the implementation team.
Their expertise would need to be in both the inner workings and implementation of the specific EHR to be implemented (from a vendors perspective) and also in the structure of the implementation team (from the hospital perspective). This person would need to have excellent communication and organizational skills as the success of the implementation really begins and ends with them. They will also need delegation skills, as there is no way they could be expected to accomplish all facets of their role without support.
It is never recommended to implement an EHR without a physician champion. A close relationship between the physician champion and the implementation team is imperative to the success of the EHR. Physicians will need the EHR to function clinically in a way that is beneficial to them as well as the patient. The Physician Champion will serve as a liaison between the implementation team and the facility physicians, so good communication skills are also required. It is essential that physicians “buy in” to the EHR, so it will be necessary for them to have a voice in the development, optimization and implementation of the EHR.
The Information Technology Lead is the person that every member of the team can go to for answers related to the operation of the software and hardware of the EHR. They deploy the workstations or other hardware needed, install the appropriate software and drivers on computers, tablets, scanners, printers and other hardware. They are also responsible for the operation of the software on the deployed hardware.
The IT Lead will need to work with Leads from all departments within the hospital (Nurse and other Clinical Leads, Lab and other Ancillary Service Leads) so good communication skills are necessary. They will also need to understand the EHR and how the software is installed and how the hardware is intended to work once the software is installed. They will need to have a working knowledge of all areas of the EHR and what each department can expect to be required to do to login, use, and troubleshoot issues that arise.
The SuperUser Lead creates a network of Super-Users within the organization to provide continued support during and after implementation of the EHR. These SuperUsers must be recruited and trained by the SuperUser Lead. SuperUsers must be personable and willing to help employees with various skills within the organization. They will need to be able to work with very computer savvy employees as well as those who have very little computer expertise.
They will provide IT support during implementation as well as assisting with new employees hired after implementation. They will be chosen based on their knowledge of different facets of the EHR so that they can provide very specific and effective assistance to employees.
Plan for Evaluation
Once an Electronic Health Record has been implemented by a team within a hospital setting, it will be important to continually evaluate the success of the EHR in the different areas of the hospital. National professional organizations have developed position papers regarding the importance of evaluation as well as methods for evaluation. One such organization, Healthcare Information and Management System Society or HIMSS, developed a position paper titled Transforming Nursing Practice Through Technology and Informatics.
In this paper, they outline the value of nursing informatics, connecting with the consumer, and implications for time and plan of care (“HIMSS,” June 16, 2011). HIMSS believes that nursing should be key stakeholders in not only the development and design of EHR, but also in the evaluation and optimization of EHR (“HIMSS,” June 16, 2011) . The position statement from HIMSS is in alignment with other professional organizations such as the American Nurses Association (ANA), and the Alliance for Nursing Informatics (ANI) (“HIMSS,” June 16, 2011).
Having strong nursing informatics leadership will play a key role in evaluating the success of system implementation. These leaders will orchestrate what information will be provided, how patient care is supported by the gathering and documentation of data and what financial and business implications there are as a result of implementation (“HIMSS,” June 16, 2011). National benchmarks exist in all service areas in the hospital.
The EHR should allow each service area to easily compile data to measure their area against national benchmarks as well as their peers. The ease in which data is gathered from the EHR will allow more time for changes in practice guidelines or protocols to provide for safer care for the patient and a better work environment for the employee. Continual evaluation by all service areas as well as discussions between unit service area leadership and nursing informatics leadership regarding possible optimizations to the EHR are imperative to a successful EHR implementation.
Mastrian, K. G., & McGonigle, D. (2017). Informatics for Health Professionals (Custom WGU ed.). [Western Governors University]. Retrieved from https://wgu.vitalsource.com/#/books/9781284155402
Position statement on transforming nursing practice through technology and informatics. (June 16, 2011). Retrieved from https://www.himss.org/sites/himssorg/files/HIMSSorg/handouts/HIMSSNIPositionStatementMonographReport.pdf
Tan, J., & Payton, F. C. (2017). Adaptive Health Management Information Systems: Concepts, Cases, & Practical Adaptions (Custom WGU ed.). [Western Governors University]. Retrieved from https://wgu.vitalsource.com/#/books/9781284155396
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C791 Advanced Information Management – Electronic Health Record (EHR) Essay
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