Electronic Health Record Implementation Comprehensive Nursing Paper Sample

Electronic Health Record Implementation Comprehensive Nursing Paper Sample

A crucial facet of health care transformation is the need to transform healthcare systems into a unified system that supports interprofessionalism and the interrelationships of Informatics and Information systems. EHR improves healthcare by aiding diseases diagnosis, preventing and reducing medical errors to enhance patient safety and support better outcomes. This paper discusses the role of EHR in care improvement, data capture, stakeholders in design and implementation of EHR, strategies for implementing EHR, professional, ethical, and regulatory standards incorporate in EHR design and implementation, measures and steps of evaluating EHR success,  and the leadership skills and theories that can facilitate collaboration between interprofessional teams.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Electronic Health Record Implementation Comprehensive Nursing Paper Sample

EHR provides an opportunity for clinical teams to track care improvement in a clinical setting. Traditionally, patient care is a nurse’s responsibility since the two spend significant time together, from admission to post-discharge. In this case, nurses need event-log and clinical datasets within EHR databases to facilitate effective care delivery.  As different nurses interact with the EHR systems, granular interactions are recorded (event log data), enlisting nurses’ activities to use the EHR systems (Adler-Milstein et al., 2020). Together with clinical data, event log data offer novel insights to support quality improvement initiatives in a clinical setting. Besides, EHR data can enhance nurses’ work-life by reducing factors that increase the burden and burnout associated with EHR use.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Traditional clinical data include content related to the patient’s medical records, such as clinical state, care decisions, and clinical notes. Nurses often peruse these data as recorded by other practitioners to gain insight into the patients’ present state and medical history and medications and orders to ensure they offer consistent care (Aspevig & Singletary, 2020). Equally, even log data provides comprehensive information that offers the opportunity for a detailed evaluation of healthcare, focusing on consumption and creation of clinical information. Informatics facilitates electronic health records, diagnostics, and treatment plans that facilitate effective and efficient care delivery through data capture. Consequently, nurses interact with the medical team for additional insight on the patient’s care trajectory based on the event log and clinical data.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Organizational support is vital in promoting informatics initiatives. Organizational leadership should assess multiple aspects of communication within and outside the EHR system, its integration with other technologies within the institution, clinical teams, processes, and culture. Consequently, communication and collaboration enhancement capability creates a platform that eases healthcare workflow management, improved coordination, and enhances patient outcomes (Lee, 2014). Moreover, there is a need to document clinical records to facilitate efficient monitoring of patients’ clinical status and access to clinical data. Through the systemized arrangement, nurses can apply available knowledge to establish an appropriate plan of action.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Another strategy to improve the use of health informatics is by involving database analysts. Patient data analysis from EHR tends to be complex, yet analysts can provide more insights on the collated data. Moreover, standardizing nursing language can encourage acceptance of adopted EHR systems (Lee, 2014). Using nursing notes can help nurses with their workload, reminding them of crucial information to be documented or applied for patient care.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

The systems involved in the design and implementation of EHR include communication and administrative systems. Communication systems are involved in patient care collaboration, patient referrals, scripts issuance, accessing lab results, and payment processing. Communication systems also facilitate the establishment of appointment reminders and include telemedicine solutions. Administrative systems include support frameworks for managing nonclinical activities, client information, financial and demographic data, and reporting capabilities. Therefore, communication and administrative systems must be integrated into the HER to facilitate its effectiveness.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Staff members involved in EHR design and implementation include team lead, implementation manager, nurse lead, physician, IT lead, Medical assistant, and laboratory staff lead. Other members of the design and implementation include billing, registration, and training lead. Significantly, nurses play a crucial role in EHR implementation since they work with IT professionals in integrating the technology with patient care to transform data into practice evidence-based practice knowledge (Daly, 2015). In this regard, APRNs assume responsibility and accountability for applying the EHR system in health promotion, assessment, diagnosis, and management of patients.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

EHR proposal implementation strategies involve a stepwise consideration of needs, adoption, system testing, education, implementation, ongoing maintenance, and optimization. First, it is vital to communicate the logic for EHR adoption, explaining to the clinical staff the benefits for each team member and improved quality of care for the patients (Aguirre et al., 2019). Equally, the team lead should communicate results by establishing a plan to measure the success of the EHR system. Such communication should be frequent at pre-defined intervals. Finally, always communicate to staff about the different phases throughout the adoption path of EHR implementation.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Before transitioning to the new EHR system, testing is necessary to ensure that every system crucial to its implementation is put in place. This will ensure that the EHR system is appropriately integrated and synchronized to allow users to collect, process, and store clinical data (Aguirre et al., 2019). Moreover, testing ensures that the EHR system interface is working as intended, workflows adjusted appropriately, and current system security features are effective. Therefore, it is vital to ruminate each of these steps to safeguard an uneven transition from the traditional data collection to the EHR system and ensure staff is well acquainted with its application.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Following the implementation, the institution management should consider training employees, optimizing, and maintaining the EHR system. This involves managing resources to ensure that users are well trained on effective and efficient use of the EHR system (Aguirre et al., 2019). In addition, factors such as unprecedented failure of the EHR system or power failure must be considered to facilitate the establishment of a recovery plan to ensure continuity of services. Finally, a training and assessment plan for users’ skills should be established to facilitate a successful EHRadoption.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

The professional, ethical, and regulatory issues that must be considered when adopting an EHR system include privacy and confidentiality of patient data, security concerns, data inaccuracies, and system implementation. Clinical data that pertains to patient treatment should not be shared without a patient’s consent or legal compulsion (Ozair, Jamshed, Sharma, & Aggarwal, 2015.). Therefore, security measures should be adopted, including robust privacy and confidentiality policies to secure patient information from access.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Furthermore,  security breaches from hackers threaten the privacy of patient data stored in EHR systems. Hackers often make available patient data without authorization or consent. Therefore, certain policies and procedures need to be put in place to maintain the privacy and confidentiality of patient data (Ozair et al., 2015). For instance, users of the EHR system should be compelled not to share their IDs with anyone. Besides, installing security measures such as intrusion detection, antivirus software, and firewalls can help boost data integrity. Moreover, installing security officers designated to assist the IT experts and conducting routine audits can ensure compliance with regulations and policies that protect data integrity.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Inaccurate data entry also compromises its accuracy and reliability, limiting its ability to improve patient safety. Because of the challenges faced in EHR implementation, organizations should provide adequate funds and involvement of employees to avoid wastage of resources, negative attitudes, and patient safety concerns (Ozair et al., 2015). Other inherent features such as cut and paste and the drop-down menu also contribute to inaccurate data representation, risking patient lives and clinician liability (Ozair et al., 2015). In this sense, EHR experts and experienced clinicians should train other clinicians to understand their contribution to EHR implementation and quality improvement and prevent software problems.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Evaluating the EHR system is centered on its reliability, performance, interoperability, standards, usability, usefulness, and customizability. Therefore, I would first determine whether the vendor of the EHR system incorporated the institutional needs (McBride & Tietze, 2016). Then, I would consider aspects such as throughput, operations, and synchronization. These aspects are crucial for effective EHR function. In this regard, I would collect information related to quality improvements, such as the EHR system integration with the existing culture, employees’ competence with the system, and the level of migration of different departments and partners to the new EHR system.

Electronic Health Record Implementation Comprehensive Nursing Paper Sample

Additionally, I would determine whether the EHR network and infrastructure are appropriate, whether the EHR captures the required data elements, and whether there are unanticipated consequences (McBride & Tietze, 2016). I would also evaluate bottlenecks, downtimes, reliability of technology tools, and security incidences of patient data. Furthermore, I would establish a communication plan to ensure employees understand the EHR system (McBride & Tietze, 2016). Consequently, providing employee provider training, change control, and revies would contribute to continuous quality improvement.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Appropriate leadership skills are necessary for a successful EHR system implementation. The leadership must have a working knowledge of technology, prioritize quality and safety and cope with changes in a clinical setting. These skills would allow the leadership to establish training opportunities and support frameworks for nurses with limited knowledge of EHR system operation and data analysis. Besides, the leadership will foster multidisciplinary relationships to facilitate appropriate and accurate clinical data and information sharing. This would allow the nursing team to synthesize and share evidence-based information to inform safety practices.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Lewin’s theory of change could be vital in implementing the EHR attributed changes.  Lewin’s theory facilitates behavioral changes, particularly among employees and institutional factors limiting a proposed change (Mitchell, 2013). The theory would alter exiting behavior (unfreezing phase), guide initiation of changes (movement phase), and establishing equilibrium between employee behavior with the adopted EHR system (refreezing). Therefore, Lewin’s theory can play a significant role in adopting, evaluating, and maintaining the EHR system.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

References

Adler-Milstein, J., Adelman, J. S., Tai-Seale, M., Patel, V. L., & Dymek, C. (2020). EHR audit logs: a new goldmine for health services research?. Journal of biomedical informatics101, 103343(Electronic Health Record Implementation Comprehensive Nursing Paper Sample). https://doi.org/10.1016/j.jbi.2019.103343

Aguirre, R. R., Suarez, O., Fuentes, M., & Sanchez-Gonzalez, M. A. (2019). Electronic health record implementation: a review of resources and tools. Cureus11(9).(Electronic Health Record Implementation Comprehensive Nursing Paper Sample) https://dx.doi.org/10.7759%2Fcureus.5649

Aspevig, J., & Singletary, V. (2020). Project Management and Public Health Informatics. In Public Health Informatics and Information Systems (pp. 221-236). Springer, Cham. https://doi.org/10.1007/978-1-4471-4237-9_12

Daly, P. (2015). Clinical nurses lead the charge with EHR. Nursing202045(10), 25-26. (Electronic Health Record Implementation Comprehensive Nursing Paper Sample)https://doi.org/10.1097/01.nurse.0000471426.47075.d2

Lee, A. (2014). The role of informatics in nursing. Nursing Made Incredibly Easy12(4), 55. 10.1097/01.NME.0000450294.60987.00

McBride, S., & Tietze, M. (2016). Nursing informatics for the advanced practice Nurse. Patient Safety, Quality, Outcomes, and Inter professionalism, 2015. McBride, S., & Tietze, M. (2016). Nursing informatics for the advanced practice Nurse. Patient Safety, Quality, Outcomes, and Inter professionalism, 2015.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management20(1), 32-37.

Ozair, F. F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical issues in electronic health records: A general overview. Perspectives in clinical research6(2), 73. https://dx.doi.org/10.4103%2F2229-3485.153997

Rouleau, G., Gagnon, M. P., Côté, J., Payne-Gagnon, J., Hudson, E., & Dubois, C. A. (2017). Impact of information and communication technologies on nursing care: results of an overview of systematic reviews. Journal of Medical Internet Research19(4), e122(Electronic Health Record Implementation Comprehensive Nursing Paper Sample). https://doi.org/10.2196/jmir.6686

Electronic Health Record Implementation Comprehensive Nursing Paper Sample

APPENDIX

APA Writing Checklist

Use this document as a checklist for each paper you will write throughout your GCU graduate program. Follow specific instructions indicated in the assignment and use this checklist to help ensure correct grammar and APA formatting. Refer to the APA resources available in the GCU Library and Student Success Center.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

☒ APA paper template (located in the Student Success Center/Writing Center) is utilized for the correct format of the paper. APA style is applied, and format is correct throughout.

☒  The title page is present. APA format is applied correctly. There are no errors.

☒ The introduction is present. APA format is applied correctly. There are no errors.

☒ Topic is well defined.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

☒ Strong thesis statement is included in the introduction of the paper.

☒ The thesis statement is consistently threaded throughout the paper and included in the conclusion.

☒ Paragraph development: Each paragraph has an introductory statement, two or three sentences as the body of the paragraph, and a transition sentence to facilitate the flow of information. The sections of the main body are organized to reflect the main points of the author. APA format is applied correctly. There are no errors.

☒ All sources are cited. APA style and format are correctly applied and are free from error.

☒ Sources are completely and correctly documented on a References page, as appropriate to assignment and APA style, and format is free of error.

Scholarly Resources: Scholarly resources are written with a focus on a specific subject discipline and usually written by an expert in the same subject field. Scholarly resources are written for an academic audience.(Electronic Health Record Implementation Comprehensive Nursing Paper Sample)

Examples of Scholarly Resources include: Academic journals, books written by experts in a field, and formally published encyclopedias and dictionaries.

Peer-Reviewed Journals: Peer-reviewed journals are evaluated prior to publication by experts in the journal’s subject discipline. This process ensures that the articles published within the journal are academically rigorous and meet the required expectations of an article in that subject discipline.

Empirical Journal Article: This type of scholarly resource is a subset of scholarly articles that reports the original finding of an observational or experimental research study. Common aspects found within an empirical article include: literature review, methodology, results, and discussion.

Adapted from “Evaluating Resources: Defining Scholarly Resources,” located in Research Guides in the GCU Library.

☒ The writer is clearly in command of standard, written, academic English. Utilize writing resources such as Grammarly, LopesWrite report, and ThinkingStorm to check your writing.