NUR 514 Patient Documentation and Nursing Informatics Sample Paper

NUR-514 Benchmark – Electronic Health Record Implementation Paper

            The healthcare frontier, specifically the nursing aspect has undergone constant evolution aimed at improving caregiving and enhancing outcomes over the years. Part of this has seen the integration of technology into professional practice to enhance service provision and follow-ups, of which nurses are increasingly part. The electronic health record (EHR) represents one such advancement and its revolution of the system is yet to be fully tapped. Accordingly, Baumann et al. (2018) contend that proper documentation and clinical information relating to patients are the cornerstone of EHR, as they enhance patient care, professional communication and improve patient outcomes. Consequently, this essay will canvas the implementation of an EHR, as relates to clinical documentation by nurses, in terms of its technological rollout, collaborative design, ethical and regulatory aspects, leadership implications as well as evaluation parameters.

Key Database Information for Tracking Improvement Opportunities

            Clinical documentation of patient data can be very arduous especially in those poorly proficient with the EHR in place or as a result of systems complexities. As such, assessing the ease of use of the EHR by nurses is important in providing feedback on its user-friendliness or competency of the caregivers (Kebede et al., 2017). These underpin an EHR’s success.

First, although assessing efficiency objectively has proved a challenge, metrics such as ‘number of clicks’ and ‘time-spent’ can be embedded in the system to a specific user’s account and used to assess the seamlessness with which they accomplish their tasks. The number of clicks denotes the times the caregiver clicks on her screen to accomplish specific clinical and administrative tasks daily and provides a rough indication of their efficiency and understanding of the system, as well as its ease of use (Sinsky et al., 2020). Additionally, the average time spent on the system, either logging in or retrieving patient data is also a useful indicator of how seamlessly the caregiver is interacting with the EHR, and as such can be used to assess the ease of nurses’ interaction with the EHR systems.

Importantly, a properly functioning EHR has to have a way of capturing individualized patient information such as biodata and biometrics for both security of patient data and follow-up to assess consumer satisfaction regarding the EHR functionality (Kutney-Lee et al., 2019).  Information gathered from the modalities provided is thus crucial in improving the EHR systems in terms of professional training as well as enhancing user-interface to realize the ultimate gains of EHR systems.

Role of Informatics in Capturing Key Database Information

            The assessment of ‘number of clicks’ and ‘time-spent’ by caregivers in handling patient data in an EHR can be accomplished using special monitoring software that is embedded into the EHR systems. The software implements one-on-one usability assessments by capturing and accurately recording caregivers’ interactions with the user interfaces through clicks and the use of prompts (Campbell & Rankin, 2018). Additionally, they analyze specific timestamps to have a general view of task completion times, the number of interactions needed to complete a task, instruction adherence and flow as well as the use of the back button (Sinsky et al., 2020). Eventually, since these are specific for one caregiver’s account in the EHR, it is easier to track and monitor one’s performance and assist where needed. However, care must be taken not to disrupt the overall functionality of the parent EHR by using several overbearing adjunct software.

Importantly, patients are central to an EHR functioning and thus their place in improving EHR systems is reserved through their provision of suggestions, experiences, and level of satisfaction. This can only be realized if their parent data is well captured and stored. Consequently, the EHR has to be fitted with a software mechanism capable of accurately taking and storing patient biometrics such as fingerprints and a full biodata set at the first patient visit (Kutney-Lee et al., 2019). These are accomplished through the use of webcams and fingerprint scanners that then upload the information to the newly created patient’s online file repository. Subsequently, any changes in the patient’s status can be safely edited on their file to improve currentness and enhance follow-up (Kutney-Lee et al., 2019). The process is critical in obtaining patient feedback, enhancing the security of patient information, and even for billing purposes. The organization of this information and its updating is duly accomplished by nurse informaticists.

Design and Implementation Process of the EHR

The development and implementation of an EHR that satisfies patient needs and is user friendly to the caregivers is a delicate task. As such, multiple considerations at various layers have to be made to ensure the ultimate gains are realized. At the basic level, specific hardware and software systems have to be acquired, and these are chosen on basis of efficiency, durability, security, and affordability. The facility needs to run on an EHR that provides for patient data safety, does not break down often, and is user-friendly (Sinsky et al., 2020). Moreover, the financial implications of such acquisition have to be in tandem with the budgetary considerations of the facility since the hardware will include portable and durable computers, UPCs, CPU, and a server room while the software will include a scanning software, biometric machine, and in-built systems monitor.

Importantly, the realization of an EHR with the outlined features will take the collaboration of different staff and non-staff members. The head nurse will be incorporated for leadership and guidance and financial advice as well as a nurse informaticist to aid in fine-tuning the final EHR outlook to fit the demands of seamless nurse caregiving. A software provider will be chosen to furnish the facility with up-to-date software for capturing patient data, storage and faithfully monitoring staff interaction with the system. Further, the records manager has to provide input on the organizational outlook and modalities of storing and retrieving information as well as access security of patient data. The physicians, physiotherapists, laboratory technicians, pharmacists, nutritionists, and surgeons/pediatricians will all provide a representative to participate in the building of such an important healthcare component. Emphasis is put on the access framework, the input of patient data, security, and retrieving patient information. All the professionals will be trained on the usage of- and assessed-the EHR to ensure adequate understanding.

Professional, Ethical and Regulatory Standards for Incorporation

            Inherently, the implementation and use of electronic patient data are guided by the HITECH Act. Due to the availing and storage of patient information to a ‘third site’ for storage online, it is fraught with specific risks such as theft, hacking, and mistakes which may end up with intricate patient information in the wrong hands (McBride e al., 2018). Consequently, operational approval by the Office of the National Coordinator for Health Information Technology’s (ONC) must involve the satisfactory demonstration of a secure system, run by competent professionals. According to McBride et al. (2018), the EHR must possess appropriate patient management software and hospital management boards ought to be vigilant for the meeting of the standards to authorize the implementation of EHR in the facility. Privacy and confidentiality of patient information have to be upheld in the highest possible standards, and line with the HIPAA 1996. This will be accomplished through conformations, encryptions, and provision of individualized accounts for caregivers on the platform. Professional competence and integrity have to be assured through appropriate qualifications, regular training, and specific systems checks to enhance proper interaction with and usage of the EHR.

Transferring of Order Sets and Communication of Changes

Order sets represent a clinical decision support tool whose role is to promote efficiency and safety in patient care. The initial step is ensuring support from all care providers from the start. To ensure the success of the transfers, it will be done in phases, likely departmental steps, as a means of implementing and continuous monitoring and re-evaluation (Li et al., 2019). The typical infrastructure will have a robust catalog, unifying formulary, order naming convention, and an intranet for processing procedures, documents, and protocols (Li et al., 2019). Further, software for tracking order set progress has to be incorporated, as are the integrated laboratory and nutritional systems (Delvaux et al., 2017). Experts and hired analysts will be initially hired to aid in the transfer as well as train the caregivers till a point they can assume functions. These changes have to be communicated using the established channel of information flow beforehand to enable caregivers to adjust appropriately when the time comes.

Modalities of Evaluating the EHR Success

In as far as the staff is involved, assessing their competencies and efficiency regularly on the use and navigation of EHR remains vital. That is done through random scheduled visits by specific professionals at the call of the hospital board, to assess the aspects of interface interaction and time spent dealing with particular patients (Sinsky et al., 2020). Also, the cognitive load of EHR on caregivers can be checked to ensure it is as minimal as possible and that the workers are providing to their professional ability’s best. Tools such as the NASA Task Load Index (TLX) can be used to give insight into the mental and physical demand as well as performance effort of the caregivers in effecting seamless EHR systems.

Patient perspective can be assessed by checking their levels of satisfaction. That is accomplished using after-therapy comment segments to allow patients to fill in their experiences with the system and where they feel improvement is needed. These patient findings are integral to the continual advancement of the EHR implementation.

Leadership Skills for Inter-professional Collaboration

            The complexity and all-involving nature of use and applicability of EHR systems call for an over-the-board collaboration for success to be realized. Among the most important characteristics required is organizational skills. That ensures all users are in tandem with what is required of them and that they undertake their tasks diligently (Kirwan et al., 2021). Also, all operators of the system must exude high integrity levels to not only preserve the sanctity of patient information but also uphold professional ethics. Communication and information flow needs to be above reproach, to ensure seamless use of the platform. Such involves timely information involving scheduled maintenance, updates and more, to avoid disruption of patient care activities (Strudwick et al., 2019). Critical thought and creativity will also be important for navigating the vast ethicolegal issues occasioned by EHR systems as well as for constantly improving the experience and patient outcomes respectively.

Based on the above discussion, the acquisition and implementation framework of an EHR system should be collaborative, time-driven and anchored on the basic tenets that govern caregiver-patient interactions. While it is imperative to consider user comfort and usability implementing an EHR system, the primary focus should be on enhanced patient experience. Arguably, an ideal EHR system ought to improve patient experience, enhance patient outcomes and lessen the nurse’s workload during use. Most importantly, the use of EHR in clinical settings must never act as substitutes to patient-nurse interactions.