Electronic Health Record Implementation
Key Information in EHR
The electronic health records (EHR) in a healthcare setting are an important data set that can be used for care improvement. Below is a list of the data sets required in the EHR that would facilitate care improvement:Electronic Health Record Implementation
- Demographic information- The most crucial demographic information for the health records include the patient name, race, date of birth to establish age, educational status, residence to establish socioeconomic status, immigration status, and gender, among other descriptive information.
- Diagnoses- This data set should include a vivid description of the patient’s health status such as the disease from which they suffer, injuries, or infections, and includes a prognosis of the condition.
- Procedures- This data set should include information on any interventions that the medical professionals provided to the patients. For care improvement, there should be an additional field that provides a description of the effectiveness of the procedures performed on the patient.
- Laboratory Tests- The EHR should include information on any lab tests done on the individual and the images from the X-rays and ultrasounds. For care improvement, these images should indicate whether the sonographers or radiographers did the imaging properly, or the laboratory tests were properly done.
- Medication- This dataset is critical in the health records for improvement because it provides information on the prescriptions, dosage, and a drug adherence report. It should also include an additional field that records the impact of the drug on patient outcomes.Electronic Health Record Implementation
Role of Informatics in Capturing Data
Health informatics play a significant role in capturing the data above by providing the technology required to store the information by filling in the data fields required. Informatics represent the intersection of practitioners and technology in storing patient information, and use the technology to enhance healthcare. Therefore, the health informatics as a concept enables practitioners to capture the data above by providing the technology and systems required to run the EHR. To add to this, Crawford (2015) contends that informatics plays an important role in capturing valuable data and analyzing it into meaningful information that is instrumental in the data analysis processes that would reveal health or patient patterns that require improvement.
Design and Implementation Process and Team
The following is a list of the staff members that should be included in the designing and implementation of the EHR;
- Program developer- the program developer’s role is to develop the EHR system, and do the technical work of establishing a system that can capture the data required.
- Nurse leader
- Lead physician
- Lead billing staff
- Lead laboratory technologist
- Registration staff
Professional, Ethical, and Regulatory Standards to Apply in Design and Implementation of EHR
Professional Standards
The first consideration in establishing an information system is sourcing for professional and qualified information technology personnel to develop the HER system. The team should hire the personnel based on merit having assessed the evidence of similar previous projects. Therefore, the organization should advertise for the position and vet the applicants based on merit and efficiency after checking the proof of their previous work done of a similar nature. Another professional standard to consider in the design of the HER is to ensure that all the information required from a patient is collected, by including the relevant fields (Amatayakul, 2017). The purpose of the HER is to collect patient data. Therefore, any HER which fails to include the most basic information fields, especially those required in data analysis for care improvement is lack of professionalism in implementing the HER concept.
Lastly, the design team must ensure that the HER has no usability issues which compromise patient information safety that violate the HIPAA rules. Examples of usability issues include challenging navigation in the HER where the users fail to understand the system’s functions, interoperability challenges, poor information display, and system automation challenges (Ohno-Machado & Séroussi, 2019). These usability issues are avoidable by hiring a competent team that understand their roles and how to execute them professionally with limited operational issues in the future.Electronic Health Record Implementation
Ethical Standards
Ethics are critical in patient health information systems, especially because they enhance the compliance with the HIPAA. An ethical principle that the designers and implementers of the HER system should follow is the principle of patient privacy and confidentiality. The personnel involved in this process should ensure that the principle of patient privacy and confidentiality is upheld by installing security features such as passwords that limit access to the patient information. Additionally, those implementing the HER must ensure that they are authorized personnel and do not share the patient information found with unauthorized personnel.
Another ethical standard that those designing and implementing this system should consider is to include information on the importance of revealing accurate information by the patient. Ozair et al. (2015) contends that patients may conceal information because of lack of confidence in the HER established by a healthcare organization. Lack of sufficient information by the patients limits the healthcare organization’s ability to improve the level and quality of care it provides to its clients. Therefore, the team hired for this process must be people who have integrity and would not engage in activities that would compromise the ethicality of the system in place, hence instilling in the patients confidence in the system.
Regulatory Standards
An important regulatory standard that the design team should consider is the HIPAA rules and regulations on patient information privacy, confidentiality, and security (Hoffman, 2016). The team must ensure that the new information system is only accessible by authorized personnel, to enhance the privacy aspect of the EHR. For instance, the subordinate staff members should not have access to the health records system because they do not handle any patient information. The design team must also ensure that the EHR system is secure by installing security measures in the healthcare organization such as adding fixtures to prevent theft of computers, and installing firewalls and antiviruses which prevent hacking and phishing of patient information.
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Ensuring Order Sets are Part of New Records
To ensure that all order sets are part of the new catalogue, it is important that the management creates an intranet for all the order sets, such that when the new system is in place, those running the HER can copy them into the new database. Another alternative would be to label the older data sets using codes so that in the new system, it would be easy to establish which order sets are yet to be incorporated. This coding system is easier because the codes are unique in this process, hence, ensuring that all the order sets are included in the new records.Electronic Health Record Implementation
Communicating Changes to the HER
Communicating changes to the HER during the transition period is critical because it helps in avoiding errors in operations, as well as confusion among the staff members. The first step is to train all the relevant personnel on how to use the new HER, so that they can familiarize with the system. This training is important and should be mandatory for all who use this system when handling patients (Gerdin, 2015). Another way to communicate these changes would be to create a knowledge repository that has all the FAQs that would arise during operations. Sometimes the employees may not fully understand the information conveyed in the training. Instead of constantly consulting with the technical team, they could easily access the information found in the knowledge repository to answer all their questions.
Evaluating Success of HER Implementation
As a member of staff, one of the ways to evaluate the success of the HER implementation would be to assess the care coordination achieved through the use of the HER. This applies to the healthcare setting. A successful HER implementation should indicate seamless interactions and exchanges of patient information among the healthcare practitioners (Ugon et al., 2018). Another way to evaluate the success of this change process would be to assess the return on investment since the HER should have a higher financial return compared to the investment costs (Sermeus et al., 2016). As a patient, one way to evaluate the success of the HER would be to assess the patient wait times. Longer wait times are indicative of workflow issues which may arise because of poor information sharing and processing patients. Therefore, a successful HER has shorter patient wait times.Electronic Health Record Implementation
Leadership Skills and Theories
The best leadership theory for the implementation of an HER would be the transformational leadership theory where the leader inspires and motivates the team to work collaboratively, while including the team in the decision-making process (Stephens, 2017). The leadership skills required for this process include creativity, dependability, and active listening.
References
Amatayakul, M. (2017). Process improvement with electronic health records. CRC press.
Crawford, Mark. 2015 “Making Data Smart: Practical Informatics is Helping Transform Data into Health Intelligence, and Now Moving into Day-to-day HIM Work” Journal of AHIMA 85, no.2 24-27.
Gerdin, J. (2015). Health careers today. Elsevier Health Sciences.
Goldstein, D. (2017). Medical informatics 20/20. Jones and Bartlett Publishers.
Hoffman, S. (2016). Electronic health records and medical big data. Cambridge Univ Press.
Ohno-Machado, L., & Séroussi, B. (2019). Medinfo 2019. IOS Press.
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
Sermeus, W., Procter, P., & Weber, P. (2016). Nursing informatics 2016. IOS Press.
Stephens, J. (2017). Leadership for Health Professionals. Jones & Bartlett Learning.
Ugon, A., Karlsson, D., Klein, G., & Moen, A. (2018). Building continents of knowledge in oceans of data. IOS Press. Electronic Health Record Implementation