NURS FPX 6614 Assessment 1 Defining a Gap in Practice

Defining a Gap in Practice: Executive Summary

This assessment will analyze care coordination with EHR use among adults with chronic diseases by developing a Population Intervention Comparison Outcomes Time (PICOT) question. Moreover, an executive summary will be briefed to decision-makers to consider the essential elements while deciding on a particular issue.

Analysis of Clinical Priorities for Adults with Chronic Conditions

Several clinical priorities must be considered for a streamlined care coordination process to improve health outcomes in adults with chronic diseases. It is imperative to prioritize managing specific chronic conditions prevalent in adult populations, such as diabetes, hypertension, cardiovascular diseases, and respiratory conditions. These conditions require long-term care through regular monitoring, medication management, and lifestyle modifications. Additionally, it is essential to emphasize preventive measures such as regular screenings, vaccination, and lifestyle modification to mitigate the progression of chronic diseases (Kompaniyets, 2021).

Healthcare professionals must focus on optimizing medication adherence, minimizing polypharmacy, and addressing potential drug interactions. While these clinical priorities are essential to consider, specific information gaps persist in the care coordination for the targeted population. These include gaps in information sharing among interprofessional team members and the need to evaluate the integration of technologies such as Electronic Health Records (EHRs) for seamless communication and coordination. Alternative scenarios and approaches include telehealth integration for remote monitoring and virtual consultations to provide real-time coordinated care to chronic disease patients (Lewinski et al., 2022).

Application of PICOT Question to Identified Gap

In adult patients with chronic diseases (P) in local healthcare organizations, does implementing a centralized Electronic Health Record (EHR) system (I) compared to no technology-oriented coordination (C) result in improved care coordination (O) within two years (T)? Change in the local hospital is deemed necessary as lack of technology causes delayed treatments due to poor communication and collaboration. Prior studies have shown that EHR use facilitates seamless sharing of patient health data across healthcare providers, reducing fragmented care and enhancing overall coordination (Watterson et al., 2020). Moreover, the selected gap in care coordination can be effectively fulfilled by using EHR as it also reduces hospital readmission rates through better-coordinated care among healthcare professionals and delivering improved quality of care to chronic disease patients (Manov et al., 2020).

Evaluating Potential Services and Resources for Care Coordination

Several services and resources can effectively deliver coordinated care in adult patients with chronic conditions. These include Electronic Health Records (EHRs), telehealth and remote monitoring services, and patient portals and apps. Integrating EHRs within local healthcare facilities can ensure health data of chronic disease patients can be readily available to all interdisciplinary team members for holistic care treatment (Watterson et al., 2020). Moreover, telehealth services are innovative and novel for remote consultation and monitoring of chronic conditions.

These services reduce the need for in-person visits and help patients receive care treatment from healthcare teams through technology (Lewinski et al., 2022). Moreover, nurses and the relevant healthcare workforce can track their vital signs remotely and manage chronic conditions effectively. The patient portals and mobile apps for self-management and communication with healthcare providers are other resources that promote care coordination and effective management of chronic diseases (Fjellså et al., 2022). The potential barriers to using these services and resources are technological, data privacy and security issues, and communication gaps between healthcare providers and patients (Lewinski et al., 2022).

Care Coordination Intervention for Chronic Disease Management

Implementing clinical pathways is the best-chosen care coordination intervention to enhance the evidence-based care coordination practice among adults with chronic health conditions. The clinical pathways are evidence-based, multidisciplinary care plans and protocols that guide healthcare professionals to deliver standardized care and promote adherence to evidence-based guidelines for chronic care management (Bardhan et al., 2020). The practical ways to implement this strategy include assembling a multidisciplinary team of healthcare professionals and developing clinical pathways using up-to-date evidence-based guidelines for patients with chronic conditions. Furthermore, integrating clinical pathways into the EHR system can facilitate healthcare professionals in providing evidence-based care coordinated plans to adults with chronic diseases (Bardhan et al., 2020). 

Nursing Diagnosis and Collaborative Care Strategy

The nursing diagnosis of chronic conditions in adults, “ineffective self-health management,” indicates that the patient is vulnerable to ill management of chronic conditions due to various factors and barriers. This is due to a lack of knowledge, resource constraints, support, and adequate care coordination to help patients manage their chronic health conditions effectively. The collaborative care approach to providing educational materials tailored to patients’ needs can empower patients with knowledge about their conditions and the importance of adherence (Orrego et al., 2021).

Moreover, technology use such as mobile apps, EHRs, and telehealth services can enhance patient monitoring and facilitate real-time communication, feedback, and patient support (Fjellså et al., 2022). For example, implementing a shared electronic health record system to enhance communication among healthcare providers can promote self-management of chronic conditions with collaborative efforts of healthcare professionals (Bardhan et al., 2020).

Planning Intervention and Desired Outcomes

Integration of EHR for care coordination requires identifying relevant stakeholders, including physicians, nurses, specialists, and support staff. Moreover, collaborating with an EHR vendor or IT department can help customize the system to chronic conditions. Training and educational programs on EHR use will promote effective use of this technology for care coordination. The protocols for care coordination will be developed and shared with relevant team members, and pilot testing will be performed (Fjellså et al., 2022). The expected outcomes for the care coordination process will be improved communication by reducing delays in information exchange and improving response time.

NURS FPX 6614 Assessment 1 Defining a Gap in Practice

Other outcomes will be increased care coordination efficiency, enhanced patient engagement, reduction in adverse events, and improved patient outcomes (Bardhan et al., 2020). The underlying assumptions include that successful implementation relies on the commitment of all stakeholders to embrace and utilize an enhanced EHR system. Moreover, it is suggested that regular feedback sessions with healthcare will identify ongoing challenges and improve workflow. Establishing a support system to address technological or health-related issues is also recommended, ensuring user confidence promptly (Watterson et al., 2020).

Conclusion

EHR use in chronic care management among adults can promote care coordination. This technology is necessary for communication to be completed on time due to various factors. The nursing diagnosis, such as poor self-management of chronic conditions, can be effectively resolved collaboratively. The EHR integration must be executed with a planned strategy to achieve desired outcomes.

References

Bardhan, I., Chen, H., & Karahanna, E. (2020). Connecting systems, data, and people: A multidisciplinary research roadmap for chronic disease management. MIS Quarterly: Management Information Systems, 44(1), 185–200. https://doi.org/10.25300/MISQ/2020/14644 

Fjellså, H. M. H., Husebø, A. M. L., & Storm, M. (2022). EHealth in care coordination for older adults living at home: Scoping review. Journal of Medical Internet Research, 24(10), e39584. https://doi.org/10.2196/39584 

Kompaniyets, L. (2021). Underlying medical conditions and severe illness among 540,667 adults hospitalized with COVID-19, march 2020–march 2021. Preventing Chronic Disease, 18. https://doi.org/10.5888/pcd18.210123 

Lewinski, A. A., Walsh, C., Rushton, S., Soliman, D., Carlson, S. M., Luedke, M. W., Halpern, D. J., Crowley, M. J., Shaw, R. J., Sharpe, J. A., Alexopoulos, A.-S., Tabriz, A. A., Dietch, J. R., Uthappa, D. M., Hwang, S., Ball Ricks, K. A., Cantrell, S., Kosinski, A. S., Ear, B., & Gordon, A. M. (2022). Telehealth for the longitudinal management of chronic conditions: Systematic review. Journal of Medical Internet Research, 24(8), e37100. https://doi.org/10.2196/37100 

NURS FPX 6614 Assessment 1 Defining a Gap in Practice

Manov, N. F., Srulovici, E., Yahalom, R., Perry-Mezre, H., Balicer, R., & Shadmi, E. (2020). Preventing hospital readmissions: Healthcare providers’ perspectives on “impactibility” beyond EHR 30-day readmission risk prediction. Journal of General Internal Medicine, 35(5), 1484–1489. https://doi.org/10.1007/s11606-020-05739-9 

Orrego, C., Ballester, M., Heymans, M., Camus, E., Groene, O., Niño de Guzman, E., Pardo‐Hernandez, H., & Sunol, R. (2021). Talking the same language on patient empowerment: Development and content validation of a taxonomy of self‐management interventions for chronic conditions. Health Expectations. https://doi.org/10.1111/hex.13303 

Watterson, J. L., Rodriguez, H. P., Aguilera, A., & Shortell, S. M. (2020). Ease of use of electronic health records and relational coordination among primary care team members. Health Care Management Review, 45(3), 1. https://doi.org/10.1097/hmr.0000000000000222