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NURS FPX 6416 Assessment 1 Needs Assessment Meeting with Stakeholders

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Capella University

NURS-FPX 6416 Managing the Nursing Informatics Life Cycle

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Needs Assessment Meeting with Stakeholders

Part 1: Introduction

Hi, everyone. My name is Emma, and I am a nurse informaticist specialist project manager. We arranged a meeting with four key stakeholders, including administrators, system end-users, nurses, and other medical professionals, to discuss the current health information system. The goal of the meeting was to solicit feedback and opinions from stakeholders and determine whether changes to the health information system are required. In this video, I will provide an overview of the meeting’s primary subjects and outcomes and an outline of the system’s impending modifications.

As a nurse informaticist specialist project manager, I evaluate our current technology framework and propose changes based on evidence-based literature and healthcare innovations. Our organization operates a manual paper-based health records system, but we intend to transition to an Electronic Health Record (EHR) system. The EHR has a greater scope in the healthcare sector as it allows medical professionals to manage patients’ information systematically (Gatiti et al., 2021). The absence of EHR integration causes numerous problems in the hospital setting.

For instance, in a non-integrated, a nurse who delivers a narcotic drug needs to record in the performance note, staff shifting report, monitoring prescription form, and paper-based or manual Medication Administration Record (MAR). Documentation or reporting errors can occur because one operation must be documented in different places. An effective integrated EHR can enable the medical staff to record the process once and update the data in other required sections (Aguirre et al., 2019)

The implementation of EHRs results in reducing medication errors, practical ways for communication and information exchange between medical professionals, lowering healthcare expenses, effectively handling patients’ health records, enhancing care quality, and contributing to improved treatment (Tayefi et al., 2021). It is estimated that implementing EHR to reduce inefficiency in healthcare can save about $191 billion to $282 billion per year (Lewkowicz et al., 2020).

It will also assist in medical processes, including quality control, evidence-based decisions, and reporting systems (Gatiti et al., 2021). However, challenges are also associated with implementing the EHR system in healthcare. For instance, disintegration of the record or connectivity issues with distinct regions, challenges in fixing errors, warning system faults, difficulties signing off a system, and medical staff attitude or preference for paper (Quinn et al., 2019).

This project’s execution is estimated to take five to six months, including training sessions, preliminary testing, and meetings, followed by actions to assess and manage the outcomes. The vision of implementing the EHR system is the execution and long-term viability of the EHR systems to manage medical professionals’ workflow, promote the standard of patient care, and safeguard patients’ safety, subsequently promoting our organization in the medical sector (Fennelly et al., 2020).

The association between the transformation project and the organization’s vision is critical for stakeholders to connect their endeavors with objectives, offer an explicit reason, and encourage stakeholders to guarantee the change meets the organization’s strategic direction (Fennelly et al., 2020).

Part 2: Questions and Explanation

Current and Desired State of the Health Information System

Our organization is currently utilizing a traditional paper-based documentation system. All clinical-related data, such as history, medical tests, medication and prescription information, and patient results, are documented on specific forms and kept in separate files (Amna et al., 2023). Our present data system is stable because medical professionals are adept at it from several years of experience, it is resistant to technical faults and cyber-security risks, and it has low initial setup and maintenance expenses (Muinga et al., 2021). However, during stakeholder meeting, medical professionals and nurses expressed concerns about issues with the present health information system.

Medical specialists are concerned that the present system makes it difficult to track patients, putting patient safety at risk. Paper records need personnel resources and take time to enter, recover, and modify, thus impeding patient care and expanding the medical staff’s workload. Furthermore, paper documents are difficult to retrieve since they are kept in particular locations, preventing rapid decision-making during an emergency. As a result, the present system lacks interconnection, making it difficult to share information between medical professionals and divisions in the organization.

]The lack of interconnection in health information systems lowers the standard of care and raises the probability of resource waste (Miandoab et al., 2023). The ideal option proposed by the stakeholders is the adoption of EHR, which will assist in streamlining the workflow, improving data security and collaboration, and minimizing employee workload. The ultimate goal is to provide standard care, improving patient safety, and execute effective change management (Aguirre et al., 2019)

Risk Assessment of the Current System 

Stakeholders, including medical professionals, highlighted various security risks associated with the present medical records system. Handwritten or paper-based records are the leading cause of medication errors during drug administration and therapy regimens, which can jeopardize patients’ safety (Utami & Nadjib, 2019). Furthermore, paper-based records are only available in select locations, for instance, the Health Information Management Services (HIMS) section, thus delaying data availability in an emergency. Such a delay leads to compromised care, affecting patient outcomes (AlSadrah, 2020). Stakeholders also identified the current manual records system as an ethical concern to patient confidentiality.

The inability to protect paper records from unwanted access leads to privacy violations, raising ethical dilemmas and damaging patients’ trust in medical facilities. Medical negligence claims pose serious legal concerns because human entries in paper-based record systems are prone to documentation errors. It is reported that about 20% of healthcare disputes are caused by mistakes in paperwork in medical settings, including missing or invalid records. These dangers affect patient safety. It emphasizes implementing changes immediately (Ghaith et al., 2022).

Information System User Best Practice 

In the stakeholders’ meeting, we addressed Evidence-Based Practices (EBP) for adopting EHR systems to improve patient care and for a user-friendly system. Training programs and educational sessions are EBP, crucial for improving medical staff’s expertise to manage the EHR system efficiently. These programs increase the medical staff’s comprehension of EHR systems and make medical providers more comfortable with this technology (Ting et al., 2021). For instance, an interventional study conducted by Musa et al. (2023), based on EHR execution understanding and training performed at a health facility, demonstrated an increased health professionals’ trust in treatment, minimized medical mistakes, and improved patient safety.

Another best practice for EHR systems is using comprehensive security mechanisms to secure patient data. Azeez and Vyver (2019), stated that Implementing safeguards such as data encryption, restricted access, and periodic security checks that comply with Health Insurance Portability and Accountability Act (HIPAA) requirements promotes the confidentiality of patients in the EHR system. Safeguarding patients’ medical data is critical for achieving patient trust while upholding the organization’s reputation. Such EBP helps organizations maximize the beneficial effects of the EHR system, enhance patient care, attain better results, and meet legislative and ethical norms.

Technology Functionality 

During discussions with stakeholders, the software and hardware features required by stakeholders for the EHR system were addressed. Stakeholders needed an extensive system that included easy-to-understand user interfaces, an effective Clinical Decision Support System (CDSS) for making suitable and on-time decisions, and compatibility features for effortless exchange of information (Zhao et al., 2023). Hardware necessities are accessible on many devices, particularly mobile phones, tablets, and computers, so providers can employ information in any situation. Safe data systems, data recovery, and backup alternatives are vital for improving patient safety (Sannino et al., 2020)

Workflow and Communication 

Now, we will discuss the workflow and communication through EHR. Implementing the EHR system is expected to improve efficiency and minimize workload. For instance, when an EHR system is implemented instead of manually managing paper-based records, our medical organization’s administrative staff’s workload and human effort are reduced. Furthermore, EHR can enhance interaction and collaboration among medical professionals by providing an extensive patient interface with updated patient care information, reducing miscommunication and boosting care coordination in the interprofessional team (Robertson et al., 2022).

However, challenges can entail positive impacts. For instance, professionals can find adjusting to new data entry methods complex, and their previous experience with paper-based entries can exacerbate their resistance. Moreover, technical glitches and system outages also cause difficulties in effectively implementing EHR systems. For example, system malfunctions, data transfer problems, or programming faults can disrupt operations and interactions, resulting in disappointment among staff. Therefore, it is crucial to mitigate these challenges (Sreenivasan, M., & Chacko, 2021)

Mitigation of Resistance to Change

Several change management principles can support overcoming opposition to change and assist stakeholders. A significant change management approach is to provide extensive training and resources. Stakeholders with expertise and comprehension to integrate novel data systems promote organizational change. Their improved trust, understanding and reduced concern about adapting to novel systems allow them to practice efficiently (Ting et al., 2021).

Transparent communication and collaboration are essential for an effective change management strategy. Efficient and open communication regarding the project’s aims, positive aspects, and outcomes can significantly impact stakeholders’ perceptions of change and help them comprehend the initiative, reducing resistance (Esmaeilzadeh et al., 2019). Moreover, establishing a feedback approach and responding to their issues aids in addressing the staff’s concerns and provides insight into the aspects that need further development. As a result, stakeholder engagement increased and encouraged them to value the change (Gui et al., 2020). These approaches reduce reluctance to change and promote the transition to implementing the updated data system.

Data Capture 

Adopting an EHR system can streamline and automate the data-entering operation. For example, data entered by a medical professional is automatically saved to a patient portal for future reference. It positively influences patient care by lowering the workload for manual data entry, eliminating care interruptions, and enhancing the standard of care by mitigating human mistakes. It can also preserve staff’s time that can be employed in delivering patient care (Kuper et al., 2010).

By employing an EHR system, medical professionals and patients can save time by saving their data in a single location, like on a patient portal (Tapuria et al., 2021). Furthermore, the EHR system can offer organized data-gathering methods to ensure that information is consistent and accurate. The EHR system can alert users and staff for details lacking to capture comprehensive information (Cerchione et al., 2023)

Process and Outcomes

Our change management strategy strives to enhance care quality, ensure patient safety, and increase patient outcomes. Our present paper-based records system barely achieves these goals. However, a practice gap needs to be filled using EHR approaches. Implementing EHRs makes information more accessible and shareable among medical professionals. This is critical to fulfill the organization’s vision of minimizing delays in care and promoting earlier detection and patient care. It aids in improving workflow, leading to improved patient safety (Gatiti et al., 2021).

Stakeholders, including medical professionals, can access patient medical data quickly, enabling well-informed and rapid decision-making. The EHR system also offers CDSS features, minimizing the chance of medical errors and establishing standard procedures for patients’ care (Zhao et al., 2023). This proposed adoption of EHR systems promotes an individualized care system in which medical professionals prioritize patient treatment. This system improves patient outcomes patient satisfaction, reduces complications, and improves the standard of care (Gatiti et al., 2021).

Conclusion

To conclude our discussion, there is an urgent need to adopt an EHR system in the medical setting to improve patient safety by reducing medication errors and treatment delays. The vision of implementing the EHR system is to manage medical professionals’ workflow and promote the standard of patient care. Change management principles, including training, education, open communication, and feedback methods, improve stakeholders’ attitudes toward novel data system adoption.

References

Aguirre, R. R., Suarez, O., Fuentes, M., & Sanchez-Gonzalez, M. A. (2019). Electronic health record implementation: A review of resources and tools. Cureushttps://doi.org/10.7759/cureus.5649

AlSadrah, S. A. (2020). Electronic medical records and health care promotion in Saudi Arabia: An overview. Saudi Medical Journal41(6), 583. https://doi.org/10.15537%2Fsmj.2020.6.25115

Amna, D., Memon, F. A., Memon, F., Halepoto, I. A., & Bhangwar, A. R. (2023). Database system for medical record keeping and retrieval. Journal of Applied Engineering & Technology (JAET)7(1), 93-104. https://doi.org/10.55447/jaet.07.01.101

Azeez, N. A., & Vyver, V. C. (2019). Security and privacy issues in e-health cloud-based system: A comprehensive content analysis. Egyptian Informatics Journal20(2), 97-108. https://doi.org/10.1016/j.eij.2018.12.001

Cerchione, R., Centobelli, P., Riccio, E., Abbate, S., & Oropallo, E. (2023). Blockchain’s coming to hospital to digitalize healthcare services: Designing a distributed electronic health record ecosystem. Technovation120, 102480. https://doi.org/10.1016/j.technovation.2022.102480

NURS FPX 6416 Assessment 1 Needs Assessment Meeting with Stakeholders

Esmaeilzadeh, P. (2019). The process of building patient trust in Health Information Exchange (HIE): The impacts of perceived benefits, perceived transparency of privacy policy, and familiarity. Communications of the Association for Information Systems45(1), 21. https://doi.org/10.17705/1CAIS.04521

Fennelly, O., Cunningham, C., Grogan, L., Cronin, H., Conor O’Shea, Roche, M., Lawlor, F., & O’Hare, N. (2020). Successfully implementing a national electronic health record: A rapid umbrella review. International Journal of Medical Informatics144, 104281–104281. https://doi.org/10.1016/j.ijmedinf.2020.104281

Gatiti, P., Ndirangu, E., Mwangi, J., Mwanzu, A., & Ramadhani, T. (2021). Enhancing healthcare quality in hospitals through electronic health records: A systematic review. Journal of Health Informatics in Developing Countries15(2), 1. https://doi.org/10.1007/978-3-319-99713-1_11

Ghaith, S., Moore, G. P., Colbenson, K. M., & Lindor, R. A. (2022). Charting practices to protect against malpractice: Case reviews and learning points. Western Journal of Emergency Medicine23(3), 412. https://doi.org/10.5811%2Fwestjem.2022.1.53894

Gui, X., Chen, Y., Zhou, X., Reynolds, T. L., Zheng, K., & Hanauer, D. A. (2020). Physician champions’ perspectives and practices on electronic health records implementation: Challenges and strategies. JAMIA Open3(1), 53-61. https://doi.org/10.1093/jamiaopen/ooz051

Kuper, K. M., Nagel, J. L., Kile, J. W., May, L. S., & Lee, F. M. (2019). The role of electronic health record and “add-on” clinical decision support systems to enhance antimicrobial stewardship programs. Infection Control & Hospital Epidemiology40(5), 501-511. https://doi.org/10.1017/ice.2019.51

Lewkowicz, D., Attila Wohlbrandt, & Boettinger, E. (2020). Economic impact of clinical decision support interventions based on electronic health records. BMC Health Services Research20(1). https://doi.org/10.1186/s12913-020-05688-3

NURS FPX 6416 Assessment 1 Needs Assessment Meeting with Stakeholders

Miandoab, T. A., Samad-Soltani, T., Jodati, A., & Rezaei-Hachesu, P. (2023). Interoperability of heterogeneous health information systems: A systematic literature review. BioMed Central Medical Informatics and Decision Making23(1), 18. https://doi.org/10.1186/s12911-023-02115-5 

Muinga, N., Abejirinde, I.-O. O., Paton, C., English, M., & Zweekhorst, M. (2021). Designing paper‐based records to improve the quality of nursing documentation in hospitals: A scoping review. Journal of Clinical Nursing30(1–2), 56. https://doi.org/10.1111/jocn.15545 

Musa, S., Dergaa, I., Yasin, R. A. S., & Singh, R. (2023). The impact of training on electronic health records related knowledge, practical competencies, and staff satisfaction: A pre-post intervention study among wellness center providers in a primary healthcare facility. Journal of Multidisciplinary Healthcare16, 1551–1563. https://doi.org/10.2147/JMDH.S414200 

Quinn, M., Forman, J., Harrod, M., Winter, S., Fowler, K. E., Krein, S. L., & Chopra, V. (2019). Electronic health records, communication, and data sharing: Challenges and opportunities for improving the diagnostic process. Diagnosis6(3), 241-248. https://doi.org/10.1515/dx-2018-0036

Robertson, S. T., Rosbergen, I. C., Burton-Jones, A., Grimley, R. S., & Brauer, S. G. (2022). The effect of the electronic health record on interprofessional practice: A systematic review. Applied Clinical Informatics13(03), 541-559. https://doi.org/10.1055/s-0042-1748855

Sannino, G., De Pietro, G., & Verde, L. (2020). Healthcare systems: An overview of the most important aspects of current and future m-health applications. Connected Health in Smart Cities, 213-231. https://doi.org/10.1007/978-3-030-27844-1_11

Sreenivasan, M., & Chacko, A. M. (2021). Interoperability issues in EHR systems: Research directions. Data Analytics in Biomedical Engineering and Healthcare, 13-28. https://doi.org/10.1016/B978-0-12-819314-3.00002-1

Tapuria, A., Porat, T., Kalra, D., Dsouza, G., Xiaohui, S., & Curcin, V. (2021). Impact of patient access to their electronic health record: Systematic review. Informatics for Health and Social Care46(2), 194-206. https://doi.org/10.1080/17538157.2021.1879810

Tayefi, M., Ngo, P., Chomutare, T., Dalianis, H., Salvi, E., Budrionis, A., & Godtliebsen, F. (2021). Challenges and opportunities beyond structured data in analysis of electronic health records. Wiley Interdisciplinary Reviews: Computational Statistics13(6), e1549. https://doi.org/10.1002/wics.1549

Ting, J., Garnett, A., & Donelle, L. (2021). Nursing education and training on electronic health record systems: An integrative review. Nurse Education in Practice55, 103168. https://doi.org/10.1016/j.nepr.2021.103168

Utami, F. A., & Nadjib, M. (2019). Electronic prescriptions to improve patient safety in hospital: A systematic review. Strengthening Hospital Competitiveness to Improve Patient Satisfaction and Better Health Outcomes4(2), 347-355 https://doi.org/10.26911/the6thicph-fp.04.17

NURS FPX 6416 Assessment 1 Needs Assessment Meeting with Stakeholders

Zhao, C., Liang, N., Zhang, H., Li, H., Yang, Y., Zong, X., Chen, Y., Wang, Y., & Shi, N. (2023). Harnessing the power of clinical decision support systems: Challenges and opportunities. Open Heart10(2), e002432–e002432. https://doi.org/10.1136/openhrt-2023-002432

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