C791 Task 1 – Information technology course

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C791 Task 1 – Information technology course

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C791 Task 1 – Information technology course
Information technology course

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Western Governors University
Course
Advanced Information Management and the Application of Technology (C791)
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Academic year2020/2021

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Advance Information Management and the Application of Technology

A1: Advantages and Disadvantages of a System Health Information System (HIS) is designed to manage healthcare data. It includes systems that collect, store, manage and transmit a patient’s electronic health record (EHR) or a hospital’s operational management. The HIS also includes systems that handle data related to activities of care providers and health organizations; it is also designed to improve patient outcome, influence policy-making decision and inform research. Security is a major concern with HIS because of the sensitive data that can be accessed and processed. (Brook,2019). The EHR contains all clinical information and demographics on the patients.

As with most man-made systems, there are always some advantages and disadvantages and with the HIS it is no different. The advantages and disadvantages revolve around usability, interoperability, scalability and compatibility. Healthcare information management systems society (HIMSS) describes usability as the effectiveness, efficiency and satisfaction with which specific users can achieve a specific task in an environment. A system with good usability improves quality of care and patient safety, decreases nurse burnout and errors, and increase adoption rates. On the other hand, a poorly designed system can cause errors and will be user unfriendly (Boldt, 2018). I have worked with “seasoned nurses” who chose early retirement because the system the facility introduced was user unfriendly. Although usability errors may not lead to adverse events, it may reflect a potential information technology (IT) related error waiting to happen. Interoperability is the ability of the HIS to exchange and make use of information. It increases nurse productivity, improves patient experience and privacy, and reduces cost and errors. Some disadvantages of interoperability are potential for cyber-attacks due to data sharing and the system not being able to exchange and make use of information because the information is from a noncompatible system. In relation to scalability – which is the

the plan of care such as making changes in medication or increasing fluid. Documenting in EHR also makes it easier for a specialist such as the oncologist seeing a patient for the first time can get the full medical history prior to seeing the patient, which will result in saving time and providing a higher level of care.

A3:Quality and Delivery of Nursing Care and Patient Outcomes

EHR will improve quality and delivery of nursing care and promote positive patient outcome. HIS provide data in real time that can be reviewed by all the care givers. The quality of the input will greatly affect the output. The EHR can provide data on a patient that could trigger preventive care for falls or skin alteration, thereby improving patient outcome. It can also provide data that support the decision-making mechanism such as drug or food allergy alerts which can prevent negative outcomes. The elimination of paper documentation will remove the risk of errors due to poor penmanship and better facilitate quality reviews across a unit or the entire facility which can be done in real time. The use of EHR in the clinical setting will enhance patient outcome and quality of care

B1:Ways QI Data Can Lead to Measurable Improvement

The health resources and services administration define quality improvement (QI) as a systemic and continuous actions that lead to measurable improvement in healthcare services and health status of targeted groups. Healthcare systems can gain knowledge from successful QI projects and apply some of the key principles of their success. (Healthcatalyst, 2019). QI can help to

improve patient outcome and lower cost. Although a QI project may increase the workload for everyone involved, the outcome gives the facility the ability to improve care and patients’ experience, prevent medical errors and decrease cost. QI can be used in the prevention of pressure injury (PI) or in decreasing fall incidents. I worked on a step-down unit at a large teaching hospital where there was a significant increase in PI, which sky-rocketed the cost of care for the hospital. Increase in PI also reflects on the quality of care provided by the team. Since most of the patients came from the intensive care units (ICU), it was collectively decided by the step-down staff, QI team and skin care team to monitor the patients’ skin integrity documentation for 6 weeks to see if the increase in incidents was based on the ICU from which the patients came or the nurses giving care. Our goal was to decrease the number of PI incidents by 75%. The patients’ activity levels, nursing documentation on skin integrity and whether documentation on protocol such as turning every 2 hours or time out of bed as tolerated were monitored, and from the information collected from the EHR, it was determined that certain nurses in the medical and cardiac ICUs engaged in workaround on skin integrity protocols and not documenting their activities accurately. Workaround decreases the intended purpose of the protocol which was the cause of the high rate for PI incidences. Based on that information the skin care team worked with the nurses by doing in-service on PI protocols and documentation. 12 weeks after the in-service, there was an 80% decrease in PI incidence and cost of care was reduced. Another way that QI data collection can lead to measurable improvement is by auditing charts for falls with or without injury. The documentation in the EHR can be reviewed after each incident to determine cause such as recent change in medication, side effects of medication, patient’s activity level at the time of the incident, the latest fall risk assessment and if protocols were in place. A fall risk assessment is done on admission and every Wednesday, after a change

possible. Patients’ privacy is very crucial and breaching that privacy is a violation of the HIPPA law.

Data backup is of utmost importance for every healthcare facility especially with the increase in manmade and natural disasters. Since the 9-11 incident the facility has used off site back up. The stakeholders have determined that it would be best to have off site back up in case of interruption in service or disaster at the facility data recovery will be easily handled.

B3:Protection of Patient Privacy An EHR protects a patient’s privacy in different ways; for instance, by requiring a username and password (PW). Further, if the system is left unattended for 45 seconds it will automatically turn off and employees accounts are monitored. At the hospital where I worked the Healthbridge system was used and may still be in use. Employees doing direct care such as nurses, physicians or dieticians have access to information that is limited to the scope of their practice. Currently Real Time is used where I work, and the same principle applies. Violation of any HIPAA standard would result in disciplinary actions, up and including termination of service.

B4:Organizational Efficiency and Productivity Adopting EHR in any facility will improve productivity and efficiency within the organization. Standardization of charting is one sure way to improve efficiency; it will also help to minimize charting errors while supporting disease-specific protocol orders such as congestive heart failure, thereby keeping all clinicians on the same pathway when caring for patients.

Having nursing documentation done in the same manner throughout the facility helps to maintain continuity of care. The EHR also gives the clinician the ability to view a patient’s health history on a single page. Using EHR will improve productivity since the documentation can be done at bedside, it also eliminates the use of paper and there will be no need to scan documents into the system. EHR provides for documentation in real time such as during a procedure which will reduce the risk for omitting important information such as medication dose and the time it was given. Entering information real time documentation in the system would also create charges to the patient’s account thus eliminating the need for someone to do that after the procedure. Training staff to use EHR effectively will reduce overall cost for the organization and productivity and efficiency will be improved.

C:Interdisciplinary Team Identification A strong and knowledgeable leadership team is need for implementing an EHR in a healthcare system. This team will be tasked with supplying the initiative to get the project off the ground, moving through implementation and on to the go-live target date. The team will be comprised of members that represent the different facets of the facility including but not limited to clinician champion, implementation manager, information technology (IT) lead, and super user.

The clinician champion would be a respected visionary who understands and values the need to standardize clinical documentation and processes. He or she will paint the big picture plans for the EHR system, communicate goals to staff and collect information regarding the system design, working to create a system that is beneficial to clinical staff and patients.

Professional organizations have developed positions or standards regarding the necessity of evaluation, and methods for doing the evaluation. The American Nurses Association (ANA) strongly supports the requirements for patient-centered EHR including standard-based EHR and the supporting infrastructure that promotes effective interprofessional and patient communication. The organization’s position is also for nurses to be an integral part of the development, design, implementation and evaluation phases of the EHR. Another standard put forth by the ANA is outcome identification. Expected outcomes must be part of the individual plan of care and should involve the patient, family, providers and key stakeholders whenever possible or appropriate. Expected outcome is defined in terms relating to the patient’s values, ethical standards, environmental, organizational and situational considerations. Associated risks, benefits, costs and evidence-based knowledge should be considered (nursingworld, 2009). The American Nursing Informatics Association (ANIA) position paper on evaluating the safety of EHR, states that the reporting process for nursing and other providers should be easier when submitting EHR-related patient safety events and ensure follow-up and communication with the original submitter of an EHR related safety event. This position helps to improve safety programs and clinicians can quickly submit reports. This link within the EHR will also support workflow, reduce time consumption and make it easier to assess and evaluate information in a timely manner (ania, 2015). It also gives the opportunity to look for trends and analyze data for continued improvement which would be beneficial to the patients and the organization. EHR continues to make improvement in the way healthcare is delivered.

References

ANIA (2015) Addressing the safety of electronic health records. Available at ania/about-us/position-statements/addressing-safety-electronic-health- records

Boldt, Kristy (2018) EHR usability: what is it, why it is important and how it can be measured? Available at medsphere

Brook, Chris (2019) What is a Health information system? Available at digitalguardian/blog/what-health-information-system

CDC (2018) Health insurance portability and accountability act of 1996 (HIPAA). Available at cdc/phlp/publications/topic/hipaa.html

Green, Jeff (2019) Creating a leadership team for successful EHR implementation.

Available at ehrinpractice/leadership-team-ehr-implementation.html Healthcatalyst (2019) The top six examples of quality improvement in healthcare. Available at healthcatalyst/insights/top-examples-quality-improvement- healthcare

Lord, Nate (2018) What is HITECH compliance? Understanding and meeting HITECH requirements. Available at digitalguardian/blog/what-hitech-compliance- understanding-and-meeting-hitech-requirements

Nursingworld (2009) Electronic health record. Available at nursingworld/practice-policy/nursing-excellence/official-position- statements/id/electronic-health-record/

A1:Advantages and Disadvantages of a System
Health Information System (HIS) is designed to manage healthcare data. It includes
systems that collect, store, manage and transmit a patient’s electronic health record (EHR) or a
hospital’s operational management. The HIS also includes systems that handle data related to
activities of care providers and health organizations; it is also designed to improve patient
outcome, influence policy-making decision and inform research. Security is a major concern
with HIS because of the sensitive data that can be accessed and processed. (Brook,2019). The
EHR contains all clinical information and demographics on the patients.
As with most man-made systems, there are always some advantages and disadvantages
and with the HIS it is no different. The advantages and disadvantages revolve around usability,
interoperability, scalability and compatibility. Healthcare information management systems
society (HIMSS) describes usability as the effectiveness, efficiency and satisfaction with which
specific users can achieve a specific task in an environment. A system with good usability
improves quality of care and patient safety, decreases nurse burnout and errors, and increase
adoption rates. On the other hand, a poorly designed system can cause errors and will be user
unfriendly (Boldt, 2018). I have worked with “seasoned nurses” who chose early retirement
because the system the facility introduced was user unfriendly. Although usability errors may not
lead to adverse events, it may reflect a potential information technology (IT) related error
waiting to happen. Interoperability is the ability of the HIS to exchange and make use of
information. It increases nurse productivity, improves patient experience and privacy, and
reduces cost and errors. Some disadvantages of interoperability are potential for cyber-attacks
due to data sharing and the system not being able to exchange and make use of information
because the information is from a noncompatible system. In relation to scalability – which is the
ability to change in size, it is very important to any facility because of the constant changes
occurring within the healthcare system. Scalability creates flexibility which makes it easier to
accommodate new information, and performance will be improved. It is also a sign of stability
and competitiveness. Disadvantages of scalability are high maintenance cost should the system
grow whenever there is a change in the way healthcare is delivered and one can lose efficiency,
or quality of care can suffer thereby affecting patient outcome. With compatibility which is the
ability of one software to communicate with other systems, it is vital for continuation of care; for
instance, a patient transferring from one facility to another for specialized care, the patient’s
record would be available to the receiving facility if there is compatibility, making it easier to
treat the patient without delay. Another advantage of compatibility is having vital signs populate
in flowsheets. It also increases the ability to share data within the system. Disadvantage of
compatibility is entering data manually from one system to another or having a system that is not
compatible to the EHR; this delays the transfer of records and treatment. It also leaves patients’
privacy vulnerable. To boost compatibility, interoperability is key, and facilities must ensure that
all computers are running on a unified system.
A2:Patient Care and Documentation
Implementation of EHR can positively impact patient care and documentation. EHR
allows for all parts of the patients’ health record to be documented in the same format, which
promotes continuity of care throughout the stay. EHR makes chart review on any issue much
easier since all parts of the charts are in the same location. Patient data from every department is
documented in the same chart making it easy for providers to know what was done in every
department. EHR has made it possible to document in real time, at the bedside, and can set off
alarms or red flags as information is entered giving providers the ability to make decisions about
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the plan of care such as making changes in medication or increasing fluid. Documenting in EHR
also makes it easier for a specialist such as the oncologist seeing a patient for the first time can
get the full medical history prior to seeing the patient, which will result in saving time and
providing a higher level of care.
A3:Quality and Delivery of Nursing Care and Patient Outcomes
EHR will improve quality and delivery of nursing care and promote positive patient
outcome. HIS provide data in real time that can be reviewed by all the care givers. The quality of
the input will greatly affect the output. The EHR can provide data on a patient that could trigger
preventive care for falls or skin alteration, thereby improving patient outcome. It can also
provide data that support the decision-making mechanism such as drug or food allergy alerts
which can prevent negative outcomes. The elimination of paper documentation will remove the
risk of errors due to poor penmanship and better facilitate quality reviews across a unit or the
entire facility which can be done in real time. The use of EHR in the clinical setting will enhance
patient outcome and quality of care
B1:Ways QI Data Can Lead to Measurable Improvement
The health resources and services administration define quality improvement (QI) as a systemic
and continuous actions that lead to measurable improvement in healthcare services and health
status of targeted groups. Healthcare systems can gain knowledge from successful QI projects
and apply some of the key principles of their success. (Healthcatalyst.com, 2019). QI can help to
improve patient outcome and lower cost. Although a QI project may increase the workload for
everyone involved, the outcome gives the facility the ability to improve care and patients’
experience, prevent medical errors and decrease cost. QI can be used in the prevention of
pressure injury (PI) or in decreasing fall incidents. I worked on a step-down unit at a large
teaching hospital where there was a significant increase in PI, which sky-rocketed the cost of
care for the hospital. Increase in PI also reflects on the quality of care provided by the team.
Since most of the patients came from the intensive care units (ICU), it was collectively decided
by the step-down staff, QI team and skin care team to monitor the patients’ skin integrity
documentation for 6 weeks to see if the increase in incidents was based on the ICU from which
the patients came or the nurses giving care. Our goal was to decrease the number of PI incidents
by 75%. The patients’ activity levels, nursing documentation on skin integrity and whether
documentation on protocol such as turning every 2 hours or time out of bed as tolerated were
monitored, and from the information collected from the EHR, it was determined that certain
nurses in the medical and cardiac ICUs engaged in workaround on skin integrity protocols and
not documenting their activities accurately. Workaround decreases the intended purpose of the
protocol which was the cause of the high rate for PI incidences. Based on that information the
skin care team worked with the nurses by doing in-service on PI protocols and documentation.
12 weeks after the in-service, there was an 80% decrease in PI incidence and cost of care was
reduced. Another way that QI data collection can lead to measurable improvement is by auditing
charts for falls with or without injury. The documentation in the EHR can be reviewed after each
incident to determine cause such as recent change in medication, side effects of medication,
patient’s activity level at the time of the incident, the latest fall risk assessment and if protocols
were in place. A fall risk assessment is done on admission and every Wednesday, after a change
in status and after an incident. Based on the patient’s assessment score, protocols are initiated.
The EHR also provides data that are used for reportable events such as sentinel events; this data
are also beneficial not only to the QI team but also the legal team if necessary.
B2:HITECH and HIPAA Security Standards and Regulations
HITECH was signed into law in 2009 to drive the adoption and meaningful use of EHR
technology by healthcare providers and their associates. Providers must also show that they are
using certified EHR technology that can be measured in quality and quantity. It also provides for
stricter enforcement of the privacy and security rules of HIPAA by mandating security audits for
all healthcare providers. It benefits patients by allowing access to their protected health
information (PHI). Although HITECH and HIPAA are separate laws, they reinforce each other.
Anyone accessing information should ensure that security measures are observed (Lord, 2018).
HIPAA’s main objective is to ensure that everyone’s health information is properly protected
while allowing the flow of data that are needed to provide and promote high quality care while
protecting the public’s health and wellbeing (CDC.gov, 2018).
In the facility where I worked, every employee would access the EHR using a computer-
generated username and a password (PW) unique to its owner. The PW is changed every 90 days
and not shared with others. No one could log into the system for another person to use. Although
nurses can see the patient list or available beds on another unit, it is a violation to access any of
these patients’ record. If a patient’s record is accessed by a nurse on another unit a red flag would
popup on the IT monitors and he or she would contact the manager of the unit from where the
record was accessed; the manager would then issue a warning to the nurse who violated the
protocol. If this is a repeat offense disciplinary actions, including termination of employment, is
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possible. Patients’ privacy is very crucial and breaching that privacy is a violation of the HIPPA
law.
Data backup is of utmost importance for every healthcare facility especially with the increase in
manmade and natural disasters. Since the 9-11 incident the facility has used off site back up. The
stakeholders have determined that it would be best to have off site back up in case of interruption
in service or disaster at the facility data recovery will be easily handled.
B3:Protection of Patient Privacy
An EHR protects a patient’s privacy in different ways; for instance, by requiring a
username and password (PW). Further, if the system is left unattended for 45 seconds it will
automatically turn off and employees accounts are monitored. At the hospital where I worked the
Healthbridge system was used and may still be in use. Employees doing direct care such as
nurses, physicians or dieticians have access to information that is limited to the scope of their
practice. Currently Real Time is used where I work, and the same principle applies. Violation of
any HIPAA standard would result in disciplinary actions, up and including termination of
service.
B4:Organizational Efficiency and Productivity
Adopting EHR in any facility will improve productivity and efficiency within the
organization. Standardization of charting is one sure way to improve efficiency; it will also help
to minimize charting errors while supporting disease-specific protocol orders such as congestive
heart failure, thereby keeping all clinicians on the same pathway when caring for patients.
Having nursing documentation done in the same manner throughout the facility helps to
maintain continuity of care. The EHR also gives the clinician the ability to view a patient’s health
history on a single page. Using EHR will improve productivity since the documentation can be
done at bedside, it also eliminates the use of paper and there will be no need to scan documents
into the system. EHR provides for documentation in real time such as during a procedure which
will reduce the risk for omitting important information such as medication dose and the time it
was given. Entering information real time documentation in the system would also create charges
to the patient’s account thus eliminating the need for someone to do that after the procedure.
Training staff to use EHR effectively will reduce overall cost for the organization and
productivity and efficiency will be improved.
C:Interdisciplinary Team Identification
A strong and knowledgeable leadership team is need for implementing an EHR in a
healthcare system. This team will be tasked with supplying the initiative to get the project off the
ground, moving through implementation and on to the go-live target date. The team will be
comprised of members that represent the different facets of the facility including but not limited
to clinician champion, implementation manager, information technology (IT) lead, and super
user.
The clinician champion would be a respected visionary who understands and values the need to
standardize clinical documentation and processes. He or she will paint the big picture plans for
the EHR system, communicate goals to staff and collect information regarding the system
design, working to create a system that is beneficial to clinical staff and patients.
The IT lead must be a good communicator, proficient with applications, analytic thinker and
support the change, and have working experience with EHR and teach other IT members how to
troubleshoot issues that may arise within the system. He or she will coordinate the technical
aspect of the project, act as liaison with vendor(s) to ensure timely completion of the project and
work with other leaders within the organization; will also evaluate, analyze and ensure there is
support for improvement at each phase of the process.
Implementation manager should be an excellent communicator, knowledgeable in different
levels of the EHR application; should have leadership qualities, organizational skills and be able
to impart what he or she know to others. He or she will be tasked with designing templates and
structures for building and testing the design, coding structure, interface hardware and tools to
assure set up and processing are accurate prior to going live
The super user will be certified in nursing informatics, be able to teach others within their area of
practice to be super users and an analytical thinker. He or she will identify and prioritize all
system requirements within the practice and effectively evaluate the capabilities of the product
for meeting the requirements. They will support IT during implementation and employees hired
after implementation.
This team should have good working relationships with each other and meet regularly to
coordinate plans that will be best for everyone. Once the implementation has been completed it is
critical for the evaluation to continue to determine the success of the EHR. (Green, 2019)
D:Plan for Evaluating Success of Implementing a System
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Professional organizations have developed positions or standards regarding the necessity
of evaluation, and methods for doing the evaluation. The American Nurses Association (ANA)
strongly supports the requirements for patient-centered EHR including standard-based EHR and
the supporting infrastructure that promotes effective interprofessional and patient
communication. The organization’s position is also for nurses to be an integral part of the
development, design, implementation and evaluation phases of the EHR. Another standard put
forth by the ANA is outcome identification. Expected outcomes must be part of the individual
plan of care and should involve the patient, family, providers and key stakeholders whenever
possible or appropriate. Expected outcome is defined in terms relating to the patient’s values,
ethical standards, environmental, organizational and situational considerations. Associated risks,
benefits, costs and evidence-based knowledge should be considered (nursingworld.org, 2009).
The American Nursing Informatics Association (ANIA) position paper on evaluating the safety
of EHR, states that the reporting process for nursing and other providers should be easier when
submitting EHR-related patient safety events and ensure follow-up and communication with the
original submitter of an EHR related safety event. This position helps to improve safety
programs and clinicians can quickly submit reports. This link within the EHR will also support
workflow, reduce time consumption and make it easier to assess and evaluate information in a
timely manner (ania.org, 2015). It also gives the opportunity to look for trends and analyze data
for continued improvement which would be beneficial to the patients and the organization. EHR
continues to make improvement in the way healthcare is delivered.
References
ANIA.org (2015) Addressing the safety of electronic health records. Available at
https://www.ania.org/about-us/position-statements/addressing-safety-electronic-health-
records
Boldt, Kristy (2018) EHR usability: what is it, why it is important and how it can be measured?
Available at https://medsphere.com
Brook, Chris (2019) What is a Health information system? Available at
https://digitalguardian.com/blog/what-health-information-system
CDC.gov (2018) Health insurance portability and accountability act of 1996 (HIPAA). Available
at https://www.cdc.gov/phlp/publications/topic/hipaa.html
Green, Jeff (2019) Creating a leadership team for successful EHR implementation.
Available at https://www.ehrinpractice.com/leadership-team-ehr-implementation.html
Healthcatalyst.com (2019) The top six examples of quality improvement in healthcare.
Available at https://www.healthcatalyst.com/insights/top-examples-quality-improvement-
healthcare
Lord, Nate (2018) What is HITECH compliance? Understanding and meeting HITECH
requirements. Available at https://digitalguardian.com/blog/what-hitech-compliance-
understanding-and-meeting-hitech-requirements
Nursingworld.org (2009) Electronic health record. Available at
https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-
statements/id/electronic-health-record/
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C791 Task 1 – Information technology course