In the proposed scenario, a Clinical Nurse Specialist (CNS) with a Post-Masters Nursing Informatics Certificate has decided that the 100 bed hospital that she works in would benefit from transitioning from paper charting to using an electronic health record (EHR) system. She has done initial clinical research and has a solid foundation of best-patient-practice reasons that support this change. She has also researched and studied the information on the government’s websites HealthIT.gov, and CMS.gov pertaining to the American Recovery and Reinvestment Act and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. HITECH is a stimulus package approved by the US government allowing $19 billion dollars to be divided between hospitals and doctors “ who demonstrate “meaningful use” of electronic medical records”(ARRA HITECH Solutions, 2015). She knows that the best way to select and institute an EHR is to assemble a team of members with various specialties pertaining to the goals outlined in the stages of HITECH. Stage 1- Data capture and sharing, Stage 2- Advance clinical processes and Stage 3- Improved outcomes. Each of these stages has it’s own meaningful use criteria. As seen in the diagram to the left.
The CNS begins by choosing the members of her team from various disciplines in the hospital. Because this will mean corporate wide changes and adoption. Her list includes the following, from the IT department, a Clinical Nursing Informatacist- chosen for a specialty in how nurses interact with software and what is required for nurses to effectively care for patients, and the Director of Clinical Informatics- chosen for an overall knowledge base of the hospitals informatics resources and requirements including what software and hardware is currently available, what has worked or failed in the past and what changes will need to happen to keep the hospital compliant with patient privacy and safety regulations.
She will also need a Corporate Project Manager to organize and disseminate information to the various off-site entities related to the facilities that will need to be on board with this change across the corporation. A Chief Medical Information Officer will be key in providing the perspective of the physicians and their particular needs and goals, and to be a liaison for the staff physicians when the EHR rollout occurs. A Chief Information Officer will bring knowledge about the hospital’s day to day functions that will need to integrate into the new EHR along with how those systems currently function.
A Chief Nursing Information Officer will have their finger on the pulse of each nursing unit and be aware of the different user interface requirements that will be needed by different departments for the the specific type of flow and care given. Lastly, a Chief Financial Officer will be able to guide the team on topics concerning governmental funding and current assets along with helping to create and maintain a budget as required with the acquisition of new software and hardware, he will also be able to work with each department’s budget makers when the time comes for allocating training hours and equipment purchases. Along the way the team will need to bring in sub-specialists to give information and feedback as they hone the new system, but for now the assembled team will be responsible for researching, choosing and implementing the best EHR for their hospital.
A.2 a-e) Choose 2 real-life computerized management systems and analyze them by comparing their advantages and disadvantages, recommend the best choice to meet the ‘MU’ requirements, describe how the features of the recommended system meet the guidelines outlined in the three stages of meaningful use, describe the impact on quality of patient care, documentation and outcomes.
The team is aware that currently they have a computerized system that they use for reporting and tracking labs, radiology and scheduling, but all documentation is paper based. They consider the price point involved with adding modules to the existing McKesson software vs purchasing and implementing an entirely new EHR called EPIC. EPIC appears to be user friendly and able to seamlessly connect all of the facilities under the umbrella of their corporation. They make a list of some of the pros and cons associated with each system.
McKesson has the upside of being a system they have already worked with and it has different programs that can be pieced together to meet some of the meaningful use (MU) criteria for compliance. They already have a working relationship with this vendor and some experience with the product. Once the discussion gets going, the team realizes that there are many more bad points than good with McKesson. In their experience, the software modules are connected in a piecemeal fashion that makes it difficult for programs to interface. Quite frequently data is just lost and not retrievable. There are different data entry systems for the different types of departments i.e. OR, ER, labor & delivery, Med/Surge, radiology, and pharmacy. The different systems do not allow for across the board data harvesting and that makes it difficult and time consuming to track reportable nursing and CMS indicators. The aesthetics of McKesson are something that is frequently complained about by the staff, due to lack of distinctive color transition and eye fatigue.
Lastly, the group is very reluctant to continue on building their EHR base with McKesson because the PCPs in the area will not be able to access hospital records, and office visit information will not be available to the hospital based staff. Due to the need for increased man hours in servicing McKesson, lack of discrete data sampling, and the poor continuity of care related to PCPs not having access to hospital data and vice versa, the team decides to choose Epic instead. Epic has the down side of being a system that will require a large initial outlay of funds. The hospital will have to purchase software, and related hardware. They will have to expand the IT and biomedical engineering departments to support and maintain the new system and equipment (something that would have been necessary to a smaller degree with McKesson).
They will have to address some retrofitting needs related to wiring and computer instillation and lastly training will be a very big issue. Despite the potential down sides, the team comes up with a long list of reasons that EPIC is the right system to choose. To begin with EPIC is all one system. It allows for seamless interdepartmental interfacing. The PCPs in the area already use a version of EPIC and this will allow for easy data exchange and a patient’s information will follow them easily. The EPIC system has a medication reconciliation form that is easily viewable to all care givers and pharmacies in the area, keeping track of each patients reported medication dose and frequency. EPIC has a ‘my chart’ feature that allows patients see labs, after visit summaries , and to interact with physicians about scheduling, medications and lab results. EPIC has many built in safe guards, including password protection, continuous backup and recovery programs so no data is lost, and the vendor provides continuing support as needed. EPIC comes in 3 pre-bundled, customizable templates, each already set up to meet the Meaningful Use (MU) criteria without having to alter the program.
The team can look at the three available options and determine if one fits them perfectly, or find the closest one and alter it to fit their specific needs. Some examples of how EPIC will meet the Stage 1 MU criteria are computerized physician order entry, checking for drug interactions and allergies automatically, tracking demographics, keeping current diagnosis, medication and allergy lists, allowing patients to have electronic access to discharge summaries, and it gives patients electronic access to physicians. Once the hospital has used EPIC for at least two years, some examples of how EPIC will help meet the Stage 2 MU criteria are ongoing patient data entry and discreet sampling for report generation. The team will continue to develop the software that demonstrates interoperability in sharing of lab results with other providers and systems. Security risk assessment will be ongoing and built into the system.
Smoking status will be tracked on all patients 13 and older and the EPIC software is designed to guide the facility from meeting the Stage 1 criteria to meeting the Stage 2 criteria. Stage 3 MU objectives are projected to improve outcomes. The team is waiting on the final ruling for what the Stage 3 guidelines will be and in the mean time they have a projected goal of focusing on primary prevention measures and improving overall population health. This will include recommended vaccination reminders, smoking cessation assistance, healthy lifestyle and meal planning recommendations, and yearly checkup reminders generated by primary physicians that will crossover to hospital patient charts. Some of the better benefits of EPIC include point and click tabs in the assessment fields, this allows for discrete sampling of information. EPIC utilizes a reporting workbench that will harvest requested, reportable data and assemble it into a user friendly template. This will benefit the hospital by reducing former man-hours required to find and collect data for clinical quality measures, public health reporting, and CMS indicators.
Discrete data sampling from EPIC will make the hospital a benefit to the community as well by allowing it to track trends and provide information to community health nurses. EPIC comes with the ability to establish hard stops and reminders that allow real-time users to be aware of needs for care coordination and patient specific follow-ups or recommended testing related to treating chronic conditions. It will also allow for symptom driven order entry fields to be immediately available in emergent situations where time taken to look for those things could mean a worse outcome. This is especially important when people present with symptoms of stroke or heart attack. Another EPIC benefit is the different levels of bedside specific PHI protection related to sensitive care. EPIC has a ‘break the glass’ functionality pertaining to all sexual assault and psychiatric admits.
This function only allows relevant staff to open and view these patients charts, any others are shown a pop-up warning and a notice is sent to start an investigation of any other person who logs in to theses charts. The team is impressed with the information provided by EPIC concerning scanning patients and medications at the bedside and the reduction in medication errors this causes. The scanners will integrate with the medication dispensing machines already in use at the hospital. One of the major benefits of EPIC is the order entry build. Each physician, with a minimal amount of training, can customize the order entry process to reflect their needs. Medication orders are instantly linked to a pharmacist to double check for allergies, and correct dosing information, and then the medication becomes available, via PYXIS machines on the unit for the RN to administer at the bedside. The bedside dosing requires the patient and medication to be scanned, further eliminating potential errors, and provides a pop-up warning if an emergency override is required during any of these
steps. While the team acknowledges that training and time to become familiar with the new charting and bedside routine changes will initially impact patient care in a negative way, they have a plan in mind to keep the patients educated on the new system changes and the anticipated better care available to the patients across the board from instituting an EHR system. Having the patients ask questions and give real time feedback will help the team tweek their training and bedside routines to give better, more organized care that results in trackable outcomes. This is just an overview of some of the many functions EPIC has that persuaded the team to choose it as the new EHR system for the hospital. (EPIC and McKesson related information was culled from the authors own experience with the systems and personal interviews with multiple members of the informatics department at St Francis Hospital, Indianapolis campus).
A.3 a) Use of Quality Improvement Data
EPIC has point and click assessment tabs and a standardized documentation format that links related data. This allows for discrete data sampling related to things like CMS indicators. The hospital will be able to track compliance with things like ‘door to EKG’ times in the emergency department, Foley catheter use and resultant CAUTIs, and the time from when a patient presents with stroke symptoms until a cat scan is done and/or whether the patient receives antithrombolytics as a result. The hospital will also be able to generate reports on errors that occur the via the Risk Monitor Pro incident tracking software. This will allow them to continue researching and improving processes.
A. 3 b) Security Standards and Methods
EPIC has 24 hour monitoring of staff use while logged in, and the records they access. This is important because hundreds of staff members will be using the system and there has to be accountability if employees were to look up their own records, or the records of friends or family. This information can be tracked and the employee interviewed and disciplined if needed. EPIC also comes equipped with incident reporting software called Risk Monitor Pro. All staff members are encouraged to use this format to report any incident that might warrant further investigation. It covers every location, type of employee, type of equipment, patient, visitor or vendor. Risk Monitor Pro forms are used to report potential or perceived injuries, faulty equipment, sentinel events and things that have the potential to cause harm or damage.
This information can be followed up on by the risk management team, so that process improvement is an ongoing process. The team works with members from the IT department and plans for primary data storage with a redundant back up storage unit that simultaneously updates so if the primary server fails there is no loss of information. They have also planned for a second, off site data storage center that can be used in case of emergency to ensure continuity of services, and keep things up and running while the primary system is off line for upgrades. Lastly back up tapes will be kept at a third site in case both of these areas are compromised, and the system can be rebooted and running again within 72 hours.
A. 3 c) Explain how the system will protect patient privacy and meet HIPAA requirements EPIC will protect patient privacy in a number of ways. End User access is limited to only being able to access the information needed to do their jobs. Making the accessible information different for nurses, physicians, registration clerks, radiology technicians, committee members etc.
Personnel will only be granted access once they have completed security training and have signed documentation stating that they understand the legal risks and responsibilities when accessing protected health information (PHI). Individuals outside the hospital will have access to EPIC as well, for example nursing home physicians. They will have a read only access granted, but will require multiple patient identifiers to access the information. Also, as mentioned earlier, EPIC will employ security related chart hard stops like ‘Break the Glass’.
A. 3 d) Explain how the recommended system meets HIPAA requirements EPIC helps to meet HIPAA requirements with automated enforcing of access policies, and pro-active alerting that links directly to the risk management department, requiring strong password policies, and automatic logout at end user work stations. EPIC allows providers to protect the integrity of data and recover original data in the case of it being altered or damaged. EPIC users are required to have appropriate training to be able to access the system, and can be locked out in the case of termination. Portable devices carry encryption software that does not allow for third party data extraction or access. EPIC can also quickly generate reports with discrete sampling related to various forms of access. The majority of compliance will be the responsibility of the staff with written policies, documented sanction programs and investigation that is on-going, consistent and documented.
A. 3 e) Describe how adopting the system will reduce costs to the organization Instituting this new system will initially generate more costs, but in the long run will save the hospital money in many ways. Meeting the ARRA/HITECH Act requirements will help to offset those cost with financial incentives and avoiding fines and penalties. Having readily available test results will decrease the costs and labor associated with repeating lost or illegible results. With superior organization and data summary tools, the cost for labor associated with studying charts individually and generating reports will be exponentially lower.
The need for transcriptionists will be greatly reduced by utilizing dictation software. Facilities for storage of paper charting cost money for upkeep and staffing. An electronic database should make billing and insurance claims easier to process and thereby generate revenue faster. The time it takes for physicians to spend going over complicated medical histories with patients is greatly reduced by having that information readily available in a database. “According to a recent study, when hospitals rely on advanced electronic health records they can save up to 10 percent per patient admission” (“Advanced EHR Cuts Hospital Costs By 10% Per Admission,” 2014).
4. A) Explain why active nursing involvement in the planning, selection, and implementation of the systems is important to the success of the implementation process and meeting meaningful use requirements
Active nursing involvement is important to the success of implementing any process that affects care given at the bedside. For the system to be optimized for use, nursing suggestions and feedback are critical. EPIC knows this and has a team of nurses on staff to work with the facility in developing end-user interface. ‘Nurses’ from the hospital include the advocates, CNS’s, NP’s, LPN’s, managers, and bedside care givers, each with a specific focus and experiences that are valuable when helping to decide how charting should work. Any thing that pulls a nurses attention away from the patient, or is distracting or difficult to work with decreases the perceived level of care and increases the potential for errors.
The health care goals of meaningful use include improving efficiency, safety and quality while decreasing discrepancies, involving patients and their families in their care, improving public health outcomes, improving care coordination, and advancing security and privacy of PHI (Gregory & Klepfer, 2010). All of these things are the foundation of every interaction a nurse has with a patient. This is why nursing is one of the most trusted professions, according to the Gallup pole website, nurses come out on top at 80% when people were asked to rate “the honesty and ethical standards of people” in different given fields (“Honesty/Ethics in Professions | Gallup Historical Trends,” n.d.).
Because standard nursing care already meets the goals outlined for meaningful use, the most important thing the average nurse can do is to work hard to be competent utilizing the selected EHR software. Advanced users and nurse leaders are important to help guide the EHR selection process in the direction that will improve the bedside interactions and user interface. Clinical nurse specialists have advanced educations and bring the nursing philosophy to the selection and implementation process. All of these roles are vital to the success of any EHR implementation.
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