Electronic health records (EHRs).

Discussions

1. Electronic Health Records

Electronic health records (EHRs) are at the center stage of the effort to improve health care quality and control costs. In addition to allowing medical practitioners to access and record clinical documentation at much faster rates, EHRs are also positively influencing care delivery and nurse-patient interaction. Yet despite the potential benefits of EHRs, their implementation can be a formidable task that has broad-reaching implications for an entire health care organization.

In this Discussion, you appraise strategies for obtaining the benefits and overcoming the challenges of implementing and using electronic health records.

To prepare

Review the implementation of EHRs in an organization. Reflect on the various approaches used.

If applicable, consider your own experiences with implementing EHRs. What were some positive aspects of the implementation? What suggestions would you make to improve the process?

Reflect on the reactions of others during the implementation process. Were concerns handled effectively?

If you have not had any experiences with an EHR implementation, talk to someone who has and get his or her feedback on the experience.

Search and indicate examples of effective and poor implementation of EHRs.

RESOURCES

Required Readings

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

Chapter 15, “The Electronic Health Record and Clinical Informatics”

This chapter describes the crucial parts of an electronic health record system and explores the benefits of implementing one.

Bates, D. W. (2010). Getting in step: Electronic health records and their role in care coordination. Journal of General Internal Medicine, 25(3), 174–176.

The author of this editorial critically analyzes current applications of electronic health records (EHRs) and their impact on cost, quality, and safety of health care delivery. The author describes a study on the use of vendor-developed EHRs in clinical practice settings, the results of which pinpointed the benefits and drawbacks of EHRs.

Cresswell, K., & Sheikh, A. (2009). The NHS Care Record Service: Recommendations from the literature on successful implementation and adoption. Informatics in Primary Care, 17(3), 153–160.

This article defines the United Kingdom’s National Health Service’s Care Record Service (NHS CRS) as a standard electronic health record system. The article describes the challenges associated with implementing this new information technology and provides recommendations for overcoming those challenges.

Fickenscher, K., & Bakerman, M. (2011). Change management in health care IT. Physician Executive, 37(2), 64–67.

This article offers strategies for health care leaders to successfully implement change programs in their organizations, especially with regard to the new standards for electronic health records (EHRs). The article provides insights on change management, the reasons people resist change, and the ways to establish a culture that is more open to change initiatives.

Gruber, N., Darragh, J., Puccia, P. H., Kadric, D. S., & Bruce, S. (2010). Embracing change to improve performance. Long-Term Living: For the Continuing Care Professional, 59(1), 28–31.

This text describes the implementation of a new electronic health record system at a 105-bed hospital related-facility. The authors highlight five key elements that were deemed necessary for a successful EHR implementation.

Hyrkäs, K., & Harvey, K. (2010). Leading innovation and change. Journal of Nursing Management, 18(1), 1–3.

According to the authors, the health care field is in need of more effective leaders who understand innovation, who appreciate diversity and change, and who can foster and implement innovation and creativity. The authors describe how nurse leaders can be instrumental in embracing and disseminating innovation throughout the health care system and provide scaffolding for subsequent articles in this issue of the journal.

Mooney, B. L., & Boyle, A. M. (2011). 10 steps to successful EHR implementation. Medical Economics, 88(9), S4–6, S8–S11.

The authors of this article describe the incentives and requirements for electronic health records (EHRs) outlined in the Health Information Technology for Economic and Clinical Health (HITECH) Act. The authors then provide 10 steps for health care leaders and organizations to follow when implementing EHRs.

Murphy, J. (2011). Leading from the future: Leadership makes a difference during electronic health record implementation. Frontiers of Health Services Management, 28(1), 25–30.

In this article, the author examines the causes behind the increasing complication of EHR implementations. In addition, the author explores the role of leadership in guiding successful EHR implementations.

Required Media

Laureate Education (Producer). (2012b). Electronic health records. Baltimore, MD: Author.

In this video, Katie Skelton, Richard Rodriguez, Carina Perez, Shannon Mori, and Carmen Ferrell describe how their hospital implemented an electronic health record. They also outline the general considerations, benefits, and support measures related to electronic health records.

2. Successful Implementation of Electronic Health Information Technology

Since the inception of the HITECH Act, health organizations have faced increased pressure to update their health information technology (HIT) resources. As discussed last week, many believe that the increased use of electronic health records and the quick and efficient communication afforded by HIT can lead to improved quality of patient care. Yet there are significant costs associated with implementing such systems. What can organizations do to ensure that the correct system is selected and that the system will be appropriate for those required to use it? Who should be involved in those decisions?

This week introduces the systems development life cycle and discusses how it can guide an organization through the complexities of adopting a new HIT system.

In this Discussion, you are asked to consider the role of nurses in the SDLC process.

To prepare:

Review the steps of the systems development life cycle.

Think about your own organization, or one with which you are familiar, and the steps the organization goes through when purchasing and implementing a new HIT system.

Consider what a nurse could contribute to decisions made at each stage when planning for new health information technology. What might be the consequences of not involving nurses?

Reflect on your own experiences with your organization selecting and implementing new technology. As an end user, do you feel you had any input in the selection or and planning of the new HIT system?

RESOURCES

Required Readings

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

Chapter 10, “Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making”

This chapter explains the systems development life cycle and explores various methods of applying it. The chapter also examines the importance of interoperability in implementing HITECH.

Chapter 11, “Administrative Information Systems”

This chapter provides an overview of agency-based health information systems. The text also details how administrators can use core business systems in their practice.

Boswell, R. A. (2011). A physician group’s movement toward electronic health records: A case study using the transtheoretical model for organizational change. Consulting Psychology Journal: Practice and Research, 63(2), 138–148.

The authors of this article present a case study on an EHR implementation in a multispecialty physician group. The case study attempts to determine actions that promote successful EHR implementation and the pros and cons of implementation.

Hsiao, J., Chang, H., & Chen, R. (2011). A study of factors affecting acceptance of hospital information systems: A nursing perspective. Journal of Nursing Research, 19(2), 150–160.

The focus of this article is to determine what factors are most important in predicting the acceptance of new health information technology. The results of the study indicated that self-efficacy, top management support, and the quality of information retrieved are the most important determinants of the willingness of nurses to adopt and use a new technology.

Kelley, T. F., Brandon, D. H., & Docherty, S. L. (2011). Electronic nursing documentation as a strategy to improve quality of patient care. Journal of Nursing Scholarship, 43(2), 154–162.

This article summarizes a literature review of the relationship between electronic health records (EHRs) and quality of patient care. The article identifies deficiencies in existing research regarding the daily interactions of nurses, patients, and electronic documentation, and it provides a comparison between electronic and paper-based documentation and its effect on quality of care.

Nurse leaders discuss the nurse’s role in driving technology decisions. (2010). Virginia Nurses Today, 18(1), 8–9.

This article summarizes a roundtable held with a number of nursing executives to discuss the role nurses should take in the selection and adoption of new technologies for health care. The executives concluded that the nurses’ goals should be to select technology that will further their ability to provide safe, quality care to their patients.

Page, D. (2011). Turning nurses into health IT superusers. Hospitals & Health Networks, 85(4), 27–28.

This article highlights the importance of involving nurses with all phases of the decision and implementation process surrounding new health information technology. The author stresses the importance of communication in the process as well as defining success.

Swab, J., & Ciotti, V. (2010). What to consider when purchasing an EHR system. hfm(Healthcare Financial Management), 64(5), 38–41.

In this article, recommendations are given for purchasing health information technology. These include selecting the appropriate vendor, carefully considering the cost of both new equipment and personnel, and involving clinicians in decisions.

Required Media

Laureate Education (Producer). (2012g). Systems development life cycle. Baltimore, MD: Author.

The systems development life cycle (SLDC) provides a framework for all of the steps necessary to implementing a new technology or process within an organization. This video explains the SDLC and how it is used in the health care field.

Optional Resources

Agency for Healthcare Research and Quality. (2005). A toolkit for redesign in health care. Retrieved from http://www.ahrq.gov/legacy/qual/toolkit/index.html

This website supplies strategies for reconfiguring and transforming a hospital’s care processes. The text breaks down the redesign process into a series of steps.

3. Understanding Workflow Design

As you explored last week, the implementation of a new technology can dramatically affect the workflow of an organization. Newly implemented technologies can initially limit the productivity of users as they adjust to their new tools. Such implementations tend to be so significant that they often require workflows to be redesigned in order to achieve improvements in safety and patient outcomes. However, before workflows can be redesigned, they must first be analyzed. This analysis includes each step in completing a certain process. Some systems duplicate efforts or contain unnecessary steps that waste time and money and could even jeopardize patient health care. By reviewing and modifying the workflow, you enable greater productivity. This drive to implement new technologies has elevated the demand for nurses who can perform workflow analysis.

In this Discussion, you explore resources that have been designed to help guide you through the process of workflow assessment.

To prepare:

· Take a few minutes and peruse the information found in the article “Workflow Assessment for Health IT Toolkit”.

o As you check out the information located on the different tabs, identify key concepts that you could use to improve a workflow in your own organization and consider how you could use them.

o Go the Research tab and identify and read one article that is of interest to you and relates to your specialty area.

RESOURCES

Required Readings

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

Chapter 14, “Nursing Informatics: Improving Workflow and Meaningful Use”

This chapter reviews the reasons for conducting workflow analysis and design. The author explains specific workflow analysis and redesign techniques.

Huser, V., Rasmussen, L. V., Oberg, R., & Starren, J. B. (2011). Implementation of workflow engine technology to deliver basic clinical decision support functionality. BMC Medical Research Methodology, 11(1), 43–61.

In this article, the authors describe an implementation of workflow engine technology to support clinical decision making. The article describes some of the pitfalls of implementation, along with successful and future elements.

Koppel, R., & Kreda, D. A. (2010). Healthcare IT usability and suitability for clinical needs: Challenges of design, workflow, and contractual relations. Studies in Health Technology and Informatics, 157, 7–14.

This article points to many health information technology designs and workflow decisions that limit their value and usage. The authors also examine the structure of the conceptual relationships between HIT vendors and the clinical facilities that purchase HIT.

U.S. Department of Health & Human Services. (n.d.b). Workflow assessment for health IT toolkit. Retrieved, June 18, 2012, from http://healthit.ahrq.gov/portal/server.pt/community/health_it_tools_and_resources/919/workflow_assessment_for_health_it_toolkit/27865

This article supplies a toolkit on the planning, design, implementation, and use of health information technology. The sections of the website provide a definition of workflow, examples of workflow tools, related anecdotes, and research.

Document: Sample Workflow of Answering a Telephone in an Office (Word document)

Required Media

Laureate Education (Producer). (2012f). System design and workflow. Baltimore, MD: Author.

This video provides an overview of how workflow modeling can be used in a health care setting to target areas for revising current practices and procedures. The video also shows how technology and informatics can be used to improve workflow efficiency and increase the quality of care.

4. Using Health Information Technology as a Source of Evidence-Based Practice

Before the digital revolution, health information technology supplied very limited support for evidence-based practice. If nurses wanted to be informed about cutting-edge research, their best bet was to either subscribe to leading journals or make periodic trips to the library. With the establishment of research databases, however, nurses became empowered to learn about and facilitate interdisciplinary and translational research. Databases are just one example of how health information technology supports evidence-based practice.

To prepare:

· Read the following scenario from the text (McGonigle & Mastrian, 2015, p. 445):

Twelve-hour shifts are problematic for patient and nurse safety, and yet hospitals continue to keep the 12-hour shift schedule. In 2004, the Institute of Medicine (Board on Health Care Services & Institute of Medicine, 2004) published a report that referred to studies as early as 1988 that discussed the negative effects of rotating shifts on intervention accuracy. Workers with 12-hour shifts realized more fatigue than workers on 8-hour shifts. In another study done in Turkey by Ilhan, Durukan, Aras, Turkcuoglu, and Aygun (2006), factors relating to increased risk for injury were age of 24 or less, less than 4 years of nursing experience, working in the surgical intensive care units, and working for more than 8 hours.

· Consider how the resources identified in the scenario above could influence an organization’s practice.

· Select an issue in your practice that is of concern to you. Using health information technology, locate at least three evidence-based practice resources that address your concern and that could possibly inform further action.

RESOURCES

Required Readings

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

Chapter 23, “Research: Data Collection, Processing, and Analytics”

The authors of this chapter relate nursing research to the foundation of knowledge model. The chapter assesses informatics tools for collecting data, storing information, and processing and analyzing data.

Chapter 25, “Translational Research: Generating Evidence for Practice”

In this chapter, the authors differentiate evidence-based practice and translation research. They also describe models used to introduce research findings intro practice.

Hynes, D. M., Weddle, T., Smith, N., Whittier, E., Atkins, D., & Francis, J. (2010). Use of health information technology to advance evidence-based care: Lessons from the VA QUERI program. Journal of General Internal Medicine, 25(Suppl. 1), S44–S49.

This article presents a study that evaluated the role of health information technology (HIT) in the Department of Veteran Affairs’ Quality Enhancement Research Initiative. The authors convey their findings on how HIT provided data and information to aid implementation research, and how implementation research helped further HIT development. Additionally, the text details methods of overcoming common HIT barriers to implementation research.

Jamal, A., McKenzie, K., & Clark, M. (2009). The impact of health information technology on the quality of medical and health care: A systematic review. Health Information Management Journal, 38(3), 26–37.

This text details a study that reviews the published evidence concerning the impact of health information technology (HIT) on the quality of health care. The study investigated the use of HIT in medical care and allied health and preventive services. The authors primarily focus on the impact of electronic health records, computerized provider order-entry, and decision support systems.

Umscheid, C. A., Williams, K., & Brennan, P. (2010). Hospital-based comparative effectiveness centers: Translating research into practice to improve the quality, safety and value of patient care. JGIM: Journal of General Internal Medicine, 25(12), 1,352–1,355.

This article revolves around the usage of the hospital-based comparative effectiveness (CE) center model. The authors highlight the model’s benefits and the increasing usage of CE evidence. The article also reviews solutions to overcoming many of the challenges to operating hospital-based CE centers.

Optional Resources

Chlan, L., Tracy, M. F., & Grossbach, I. (2011). Pulmonary care. Achieving quality patient-ventilator management: Advancing evidence-based nursing care. Critical Care Nurse, 31(6), 46–50.

5. HITECH Legislation

In order for organizations to receive the incentives offered through the HITECH legislation, they must be able to demonstrate that they are using the technology in meaningful ways. The following criteria for meaningful use must be evident to qualify for EHR incentives (U.S. Department of Health & Human Services, 2012). The technology must:

· Improve quality, safety, and efficiency, and reduce health disparities

· Engage patients and families

· Improve care coordination

· Improve population and public health

· Ensure adequate privacy and security protections for personal health information

For this Discussion, you consider the impact of the meaningful use criteria of the HITECH legislation on the adoption of health information technology.

To prepare:

· Review the Learning Resources on the HITECH legislation and its primary goals.

· Reflect on the positive and negative impact this legislation has had on your organization or one with which you are familiar.

· Consider the incentives to encourage the use of EHRs. Focus on the definition of meaningful use and how it is measured.

· Reflect on how the incentives and meaningful use impact the quality of patient care.

· Find an article dealing with one of the criteria to qualify for meaningful use and how it has been successfully met.

RESOURCES

Required Readings

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

Chapter 9, “Legislative Aspects of Nursing Informatics: HITECH and HIPAA”

This chapter explores two pieces of legislation that dramatically impact nursing informatics: the Health Information Technology for Economic and Clinical Health Act of 2009 and the Health Insurance Portability and Accountability Act of 1996.

Arlotto, P. (2010). 7 strategies for improving HITECH readiness. hfm(Healthcare Financial Management), 64(11), 90–96.

This article reviews seven strategies to help prepare for the implementation of the Health Information Technology for Economic and Clinical Health Act (HITECH). The central point of the article focuses on demonstrating meaningful use of electronic health records.

Begum, R., Smith Ryan, M., Winther, C. H., Wang, J. J., Bardach, N. S., Parsons, A. H., & … Adams Dudley, R. (2013). Small Practices’ Experience With EHR, Quality Measurement, and Incentives. American Journal Of Managed Care, 19eSP12–8.

This article presents a study of clinician’s attitudes toward the use of financial incentives for the implementation of electronic health records in small practices.

Brown, B. (2010). The final rules for meaningful use of EHRs. Journal of Health Care Compliance, 12(5), 49–50.

In this article, the author poses four questions pertaining to the EHR system in the United States. In particular, the article examines Medicare and Medicaid incentive payments and the ways the meaningful use of certified EHRs will be verified.

Classen, D. C., & Bates, D. W. (2011). Finding the meaning in meaningful use. New England Journal of Medicine, 365(9), 855–858.

This article details the challenges of meeting the meaningful use standards in order to receive the benefits legislated under the HITECH Act. The authors specify the requisites for achieving benefits with EHRs, the relationship between meaningful use and commercial EHRs, and the tools needed to evaluate EHRs after implementation.

Kempfert, A. E., & Reed, B. D. (2011). Health care reform in the United States: HITECH Act and HIPAA privacy, security, and enforcement Issues. FDCC Quarterly, 61(3), 240–273.

The authors of this article examine HITECH, in addition to the impact of the privacy rules under the Health Insurance Portability and Accountability Act (HIPAA). The article details the potential negative repercussions of failing to comply with HIPAA and HITECH.

Murphy, J. (2010b). Nursing informatics. The journey to meaningful use of electronic health records. Nursing Economic$, 28(4), 283–286.

This article reviews HITECH and the background leading up to its passage. The author also details the financial incentives intended to assist health care providers in purchasing and implementing HIT and EHR systems.

Optional Resources

U.S. Department of Health & Human Services. (2011). Health IT home. Retrieved from http://www.healthit.gov/

U.S. Department of Health & Human Services. (2012). Regulations and guidance. Retrieved from http://www.healthit.gov/policy-researchers-implementers/health-it-rules-regulations

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Electronic health records (EHRs)