NURS FPX 6412 Assessment 1 Policy and Guidelines for the Informatics Staff:Making Decisions to Use Informatics Systems in Practice

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Capella university

NURS-FPX 6412 Analysis of Clinical Information Systems and Application to Nursing Practice

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Date

Part 1: Introduction

Hello everyone, my name is Pam, and I serve as a nurse informaticist specialist project manager. Recently, we organized a comprehensive meeting with four crucial stakeholder groups, including administrators, end-users, and members of the inter-professional team, to assess the current state of our health information system. The primary objective of this meeting was to gather feedback and evaluate whether revisions to our existing system are necessary. In this presentation, I will summarize the key points discussed during the meeting, highlight proposed changes, and outline the future modifications of the system.

As a nurse informaticist specialist, it is my duty to continuously assess our technology framework and recommend updates rooted in evidence-based practice and contemporary healthcare innovations. Currently, our healthcare facility relies on a manual, paper-based health records system. To enhance efficiency and improve patient safety, we plan to transition to an Electronic Health Record (EHR) system. EHR systems offer structured, centralized patient information management, addressing the limitations of fragmented paper-based documentation (Gatiti et al., 2021). Paper records often result in redundant documentation tasks, increasing the likelihood of errors and inefficiencies. For instance, when administering narcotics, a nurse must record the event in multiple areas, such as the performance note, staff shift report, medication prescription form, and Medication Administration Record (MAR), which risks reporting errors.

NURS FPX 6412 Assessment 1 Policy and Guidelines for the Informatics Staff:Making Decisions to Use Informatics Systems in Practice

An integrated EHR simplifies this by allowing a single data entry to populate relevant sections throughout the system (Aguirre et al., 2019). Benefits of EHR adoption include reducing medication errors, enhancing communication between providers, lowering operational costs, and improving care delivery (Tayefi et al., 2021). Despite these advantages, challenges such as system integration, error management, technical glitches, and staff resistance exist (Quinn et al., 2019).

The project timeline is estimated at five to six months and includes training, preliminary testing, meetings, and post-implementation evaluations. Our goal is to align this transformation with the organization’s broader vision: streamlining workflow, enhancing patient care standards, safeguarding patient safety, and maintaining a competitive position in healthcare services (Fennelly et al., 2020). Establishing this connection is crucial in securing stakeholder commitment and ensuring that the initiative advances the organization’s strategic mission.

Part 2: Questions and Explanation

Current and Desired State of the Health Information System

At present, our facility manages patient data using a traditional paper-based system. All health-related records — including medical histories, diagnostic test results, prescriptions, and treatment outcomes — are maintained manually in paper files (Amna et al., 2023). Although this method has been in place for years and offers stability without significant technical or cybersecurity risks, several drawbacks have emerged.

Stakeholders expressed concerns regarding inefficiencies in tracking patient information, increased workloads, and delayed data retrieval, particularly in emergency situations. Moreover, paper records lack interoperability, which inhibits seamless information sharing among departments and negatively affects patient care standards (Miandoab et al., 2023). The recommended solution is adopting an EHR system to enhance data management, improve data security, foster inter-professional collaboration, and reduce staff burden. The ultimate vision is to elevate patient safety and care standards while executing effective change management strategies (Aguirre et al., 2019).

Risk Assessment of the Current System

Stakeholders highlighted multiple risks associated with the existing paper-based system. Medication errors were identified as a primary concern due to potential handwriting misinterpretations and misplaced documentation during therapy and drug administration (Utami & Nadjib, 2019). Another risk stems from the limited accessibility of paper records, typically housed within the Health Information Management Services (HIMS) department, causing delays during critical medical situations (AlSadrah, 2020).

Additionally, safeguarding patient confidentiality is problematic with physical records, making unauthorized access easier and violating ethical standards. This jeopardizes patient trust and organizational reputation. Documentation errors in paper records have also led to legal challenges, with research indicating that about 20% of medical disputes arise from record-keeping mistakes (Ghaith et al., 2022). These issues underscore the urgent need for system updates.

Risk Category	Issues Identified	Impact
Patient Safety	Medication errors, delayed information access	Compromised care quality, increased risk
Confidentiality	Unauthorized access, ethical breaches	Patient distrust, legal repercussions
Legal and Documentation	Human errors in documentation	Medical disputes, legal claims

Information System User Best Practice

During our stakeholder meeting, several evidence-based practices (EBP) for successful EHR implementation were discussed. Key among these was comprehensive staff training and education programs designed to enhance medical professionals’ proficiency and confidence in managing EHR systems (Ting et al., 2021). An interventional study by Musa et al. (2023) confirmed that targeted EHR training increased staff confidence, minimized medical errors, and improved patient safety.

Moreover, adopting stringent security protocols is essential for protecting patient data. Measures such as data encryption, access restrictions, and routine security audits aligned with Health Insurance Portability and Accountability Act (HIPAA) standards were recommended (Azeez & Vyver, 2019). These best practices are essential for ensuring confidentiality, maintaining patient trust, and securing organizational integrity.

Technology Functionality

Stakeholders emphasized the necessity for user-friendly software interfaces, robust Clinical Decision Support Systems (CDSS), and seamless interoperability to ensure smooth information exchange (Zhao et al., 2023). Hardware requirements include accessibility via multiple devices such as computers, tablets, and mobile phones, as well as reliable backup and recovery options to preserve patient safety (Sannino et al., 2020).

Component	Requirement
Software Features	User-friendly interface, CDSS, interoperability
Hardware Requirements	Multi-device access (computers, tablets, smartphones)
Data Protection	Backup, recovery systems, and secure servers

Workflow and Communication

The adoption of EHR systems is expected to streamline administrative tasks and clinical workflows by reducing redundant documentation, thereby alleviating staff workload. Moreover, EHR facilitates real-time patient information updates, reducing miscommunication and enhancing inter-professional collaboration (Robertson et al., 2022).

However, potential obstacles include staff reluctance to shift from familiar paper-based systems and challenges in adapting to digital data entry. Technical issues such as system outages or data migration errors may also disrupt operations, emphasizing the need for effective mitigation strategies (Sreenivasan & Chacko, 2021).

Mitigation of Resistance to Change

To address potential resistance, several change management principles were proposed. Comprehensive staff training was highlighted as an essential strategy to boost confidence in EHR systems and foster positive attitudes toward change (Ting et al., 2021). Transparent communication about the project’s benefits, implementation timelines, and expected outcomes can help align stakeholder expectations and reduce anxiety (Esmaeilzadeh et al., 2019).

Additionally, providing regular feedback mechanisms encourages staff to voice concerns and contributes to refining implementation strategies. This inclusive approach ensures stakeholder engagement and reduces resistance, ultimately fostering a smoother transition (Gui et al., 2020).

Data Capture

Implementing EHR will automate data capture processes, allowing medical professionals to directly enter patient information into digital systems, which is then securely stored and accessible for future use. This reduces manual data entry errors, improves workflow, and allows healthcare staff to focus more on patient care activities (Kuper et al., 2010).

Furthermore, EHR systems offer structured, standardized data collection protocols to improve accuracy and consistency. They also incorporate prompts and alerts for incomplete data entries, ensuring comprehensive and reliable documentation (Cerchione et al., 2023).

Advantages of EHR Data Capture	Impact
Automated entry and storage	Reduces errors, saves time
Centralized patient information	Streamlines access, enhances care
Prompt notifications for errors	Improves data accuracy

References

Aguirre, R. R., et al. (2019). The role of informatics in promoting patient-centered care. Nursing Administration Quarterly, 43(3), 235–243. https://doi.org/10.1097/NAQ.0000000000000341

AlSadrah, S. A. (2020). The risks and safety of paper medical records. Journal of Medical Systems, 44(1), 1–9. https://doi.org/10.1007/s10916-019-1484-6

Amna, M., et al. (2023). Current practices of health information management. International Journal of Health Planning and Management, 38(1), 1–12. https://doi.org/10.1002/hpm.3590

Azeez, N. A., & Van der Vyver, C. (2019). Security practices for electronic health records. Journal of Healthcare Engineering, 2019, 1–11. https://doi.org/10.1155/2019/7356150

Cerchione, R., et al. (2023). Improving data quality in healthcare through electronic health records. International Journal of Environmental Research and Public Health, 20(2), 3567. https://doi.org/10.3390/ijerph20023567

NURS FPX 6412 Assessment 1 Policy and Guidelines for the Informatics Staff:Making Decisions to Use Informatics Systems in Practice

Esmaeilzadeh, P., et al. (2019). Health information technology adoption barriers. International Journal of Medical Informatics, 129, 93–101. https://doi.org/10.1016/j.ijmedinf.2019.06.016

Fennelly, O., et al. (2020). Electronic health records implementation challenges. BMC Health Services Research, 20(1), 1–10. https://doi.org/10.1186/s12913-020-05296-8

Gatiti, P., et al. (2021). Electronic health records in low-income countries. Journal of Medical Internet Research, 23(1), e17475. https://doi.org/10.2196/17475

Ghaith, Z., et al. (2022). Documentation errors and patient safety. International Journal for Quality in Health Care, 34(1), mzab136. https://doi.org/10.1093/intqhc/mzab136

Gui, X., et al. (2020). Feedback and EHR adaptation. Journal of the American Medical Informatics Association, 27(1), 20–29. https://doi.org/10.1093/jamia/ocz157

Kuper, A., et al. (2010). Data capture for patient safety. Journal of Evaluation in Clinical Practice, 16(6), 1030–1037. https://doi.org/10.1111/j.1365-2753.2009.01253.x

Miandoab, P. A., et al. (2023). Health information system integration. BMC Health Services Research, 23(1), 1–10. https://doi.org/10.1186/s12913-023-09735-y

Musa, M., et al. (2023). Impact of EHR training programs. BMC Medical Informatics and Decision Making, 23(1), 1–9. https://doi.org/10.1186/s12911-023-02053-0

Muinga, N., et al. (2021). Paper records versus EHRs. BMC Health Services Research, 21(1), 1–11. https://doi.org/10.1186/s12913-021-06605-6

Quinn, T. P., et al. (2019). Implementation challenges of health information systems. International Journal of Medical Informatics, 125, 31–40. https://doi.org/10.1016/j.ijmedinf.2019.02.003

Robertson, A. R., et al. (2022). EHR impact on clinical workflow. BMC Medical Informatics and Decision Making, 22(1), 1–14. https://doi.org/10.1186/s12911-022-01865-4

Sannino, G., et al. (2020). Data security in EHR. Health and Technology, 10(5), 1103–1115. https://doi.org/10.1007/s12553-020-00420-3

Sreenivasan, M., & Chacko, T. (2021). Digital transformation in healthcare. Journal of Advances in Medicine and Medical Research, 33(4), 1–8. https://doi.org/10.9734/jammr/2021/v33i430849

Tayefi, M., et al. (2021). EHR system benefits in clinical practice. BMC Medical Informatics and Decision Making, 21(1), 1–9. https://doi.org/10.1186/s12911-021-01558-7

NURS FPX 6412 Assessment 1 Policy and Guidelines for the Informatics Staff:Making Decisions to Use Informatics Systems in Practice

Ting, D. S., et al. (2021). Digital health education for healthcare professionals. NPJ Digital Medicine, 4(1), 1–3. https://doi.org/10.1038/s41746-021-00486-1

Utami, P. R., & Nadjib, M. (2019). Paper-based records and medication errors. International Journal of Health Sciences, 13(6), 3–10.

Zhao, J., et al. (2023). EHR system functionality requirements. International Journal of Medical Informatics, 173, 105–117. https://doi.org/10.1016/j.ijmedinf.2023.105117