Description
Complete three EHR Go activities relating to medication reports, order verification, and risks and clinical warnings. Write a reflection paper (one page) addressing key lessons learned relating to EHR accuracy and standards, data mining, and legal and ethical considerations surrounding EHR-CDS usage.
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Introduction
Data mining is the process of discovering and extracting patterns within a set of data. Its main goal is to transform data into meaningful information, typically for decision-making purposes. Identifying patterns within data helps to depict the data and to predict future behaviors or patterns. Information such as this helps to improve quality of care, reduce costs, and support organizational services, such as disease management and resource utilization. Historically, conducting this kind of research was extremely labor intensive. With the advent of electronic health record systems and clinical decision support (CDS) systems, health care professionals now have access to large volumes of highly standardized and electronically stored data.
One type of CDS system involves itemizing a set of symptoms and circumstances and then searching the potential range of diagnoses as the source of those symptoms. A set of internal organizational guidelines govern the use of these activities within the CDS system. The high-level concept is to build an application capable of integrating the information and then identifying a potential diagnosis in the same way a human expert would make a diagnosis.
A wide range of potential ethical and legal issues relate to the creation, implementation, and use of CDS systems. Clinical decision support assists with analyzing and interpreting health data and then offering recommendations based on that data. An example of a legal and ethical issue related to the proper use of these systems involves practitioners’ ethical responsibilities. Do practitioners fully understand the implications of following the software recommendations when treating a patient?
The three EHR Go activities that form the bulk of this assessment show that data analysts need to be knowledgeable about a large amount of material. At the same time, it’s not sufficient to have a grasp of this information in isolation. Professional data analysts need to be able to integrate this information into a meaningful whole. They need to be able to see the big picture. How do the pieces of information relate to each other? As an example, incorrect data n the health record affects data mining activities. This, in turn, affects statistical results, which may result in a bad clinical decision. Alerts, warnings, and recommendations exist to help improve documentation but care also needs to be taken to ensure data security.
In this third course assessment, you will complete EHR Go activities related to EHR accuracy and standards, data mining activities used to extract useful information for improving patient care, and the legal and ethical considerations surrounding EHR and CDS usage. In the second part of this assessment, you will integrate the key takeaways you’ve learned from completing the activities into a meaningful whole by writing a brief reflection paper.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
Competency 1: Examine analytics and decision support.
Recognize internet, cybersecurity, and mobile device security threats, including the sharing of patient information without written consent.
Describe strategies for developing standards and guidelines to protect electronically accessible health information.
Competency 2: Apply report generation technologies to facilitate decision making.
Explain data mining’s role in measuring CDS systems’ accuracy and efficiency and in generating reports.
Recommend EHR-CDS functions that support effective clinical decision making relating to medication.
Competency 4: Apply data extraction methodologies.
Use EHR-CDS functions to create a medication report based on patient chart information.
Use EHR-CDS functions to assess potential contraindications, and warnings and precautions information.
Competency 5: Evaluate data used for medical staff credentialing.
Describe a clinician’s role in overriding CDS system information.
Competency 6: Communicate effectively in a professional manner.
Write clear, well-organized, professional documents that are generally free of errors in grammar, punctuation, and spelling.
Follow APA style and formatting guidelines for citations and references.
Preparation
Independent Research
If you are less familiar with EHRs and CDS systems, you may wish to conduct additional independent research. The suggested resources provide a good starting point. You may also wish to consult the Health Care Administration Undergraduate Library Research Guide for research tips and help in identifying current, scholarly and/or authoritative sources.
Instructions
Your third assessment consists of two parts:
Part 1: Complete these three EHR Go activities
These three activities form the bulk of this assessment:
For this first activity, you will use EHR-CDS functions to create a medication report based on patient chart information. You will then use the created report to make recommendations about how to improve EHR-CDS functions for more effective clinical decision making.
EHR Go: Medication Report.
Enter your answers for this activity directly into a Word document. Also, copy and paste the medication report into the same Word document.
In the second activity, you will use clinical decision support functions, such as CPOE, to enter physician medication orders.
EHR Go: Verifying Orders.
Add your answers for this activity directly into the Word document you’ve created for your EHR Go activities.
In the third EHR Go activity, you will analyze a physician’s actions, document an EHR, and recommend physician performance requirements for using EHR clinical decision functions. The recommendations and standards will focus on physician order entry, medication warnings, and alerts.
EHR Go: Risks and Clinical Warnings
Add your answers for this activity directly into the Word document you’ve created for your EHR Go activities.
You will create one document that contains your answers to each of the three activities. Remember to copy and paste the medication report you created for the first activity into your document.
Part 2: Write a one-page reflection paper on the topics covered in the EHR Go activities
Be sure to address these three questions in your reflection paper:
What is the relationship between the three EHR Go activities you completed? In other words, how do the concepts you learned relate to each other?
What were your two or three most important takeaways about the concepts of EHR accuracy and standards, data mining, and legal and ethical considerations?
What is a remaining question you have about these concepts?
Reminders:
Your takeaways may be new information that you didn’t know before or they may confirm what you already knew.
Be sure to include supporting examples in your reflection paper along with references to current, scholarly, and/or authoritative sources.
Additional Requirements
Length: One-page, double-spaced reflection paper.
EHR Go activities: Submit your completed EHR Go activities in a Word document. Remember to copy and paste your medication report into this document.
Font: Times Roman, 12 point font.
Writing: Create clear, well-organized, professional documents that are generally free of errors in grammar, punctuation, and spelling.
APA: Follow APA style and formatting guidelines for citations and references. This guide is a good APA refresher: Evidence and APA.
Reflection on EHR Accuracy, Data Mining, and Clinical Decision Making Scoring Guide
CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Recognize internet, cybersecurity, and mobile device security threats, including the sharing of patient information without written consent. Does not recognize internet, cybersecurity, and mobile device security threats, including the sharing of patient information without written consent. Recognizes internet, cybersecurity, and mobile device security threats, including the sharing of patient information without written consent. However, omissions and/or errors exist. Recognizes internet, cybersecurity, and mobile device security threats, including the sharing of patient information without written consent. Recognizes internet, cybersecurity, and mobile device security threats, including the sharing of patient information without written consent. Includes explanations as to why these technologies are security threats.
Describe strategies for developing standards and guidelines to protect electronically accessible health information. Does not describe strategies for developing standards and guidelines to protect electronically accessible health information. Describes strategies for developing standards and guidelines to protect electronically accessible health information in minimal depth and detail. Describes strategies for developing standards and guidelines to protect electronically accessible health information. Describes strategies for developing standards and guidelines to protect electronically accessible health information. Substantiates strategies with multiple examples and references to current, scholarly, and/or authoritative sources.
Explain data mining’s role in measuring CDS systems’ accuracy and efficiency and in generating reports. Does not explain data mining’s role in measuring CDS systems’ accuracy and efficiency and in generating reports. Explains data mining’s role in measuring CDS systems’ accuracy and efficiency and in generating reports in minimal depth and detail. Explains data mining’s role in measuring CDS systems’ accuracy and efficiency and in generating reports. Explains data mining’s role in measuring CDS systems’ accuracy and efficiency and in generating reports. Explanation includes multiple examples and references to current, scholarly, and/or authoritative sources.
Recommend EHR-CDS functions that support effective clinical decision making relating to medication. Does not recommend EHR-CDS functions that support effective clinical decision making relating to medication. Attempts to recommend EHR-CDS functions that support effective clinical decision making relating to medication. However, omissions and/or errors exist. Recommends EHR-CDS functions that support effective clinical decision making relating to medication. Recommends EHR-CDS functions that support effective clinical decision making relating to medication. Supports recommendations with multiple examples and references to current, scholarly, and/or authoritative sources.
Use EHR-CDS functions to create a medication report based on patient chart information. Does not use EHR-CDS functions to create a medication report based on patient chart information. Attempts to use EHR-CDS functions to create a medication report based on patient chart information. However, omissions and/or errors exist. Uses EHR-CDS functions to create a medication report based on patient chart information. Uses EHR-CDS functions to create a medication report based on patient chart information without errors or omissions.
Use EHR-CDS functions to assess potential contraindications, and warnings and precautions information. Does not use EHR-CDS functions to assess potential contraindications, and warnings and precautions information. Attempts to use EHR-CDS functions to assess potential contraindications, and warnings and precautions information. However, omissions and/or errors exist. Uses EHR-CDS functions to assess potential contraindications, and warnings and precautions information. Uses EHR-CDS functions to assess potential contraindications, and warnings and precautions information without errors or omissions.
Describe a clinician’s role in overriding CDS system information. Does not describe clinicians’ role in overriding CDS system information. Describes clinicians’ role in overriding CDS system information in minimal depth and detail. Describes clinicians’ role in overriding CDS system information. Describes clinicians’ role in overriding CDS system information. Description includes multiple examples and references to current, scholarly, and/or authoritative sources.
Write clear, well organized, professional documents that are generally free of errors in grammar, punctuation, and spelling. Does not write clear, well organized, professional documents that are generally free of errors in grammar, punctuation, and spelling. Attempts to write clear, well organized, professional documents that are generally free of errors in grammar, punctuation, and spelling. However, lapses, omissions, and/or errors exist. Writes clear, well organized, professional documents that are generally free of errors in grammar, punctuation, and spelling. Writes clear, well organized, professional, and error-free documents. Documents include multiple examples and references to current, scholarly, and/or authoritative sources.
Follow APA style and formatting guidelines for citations and references. Does not follow APA style and formatting guidelines for citations and references. Attempts to follow APA style and formatting guidelines for citations and references. However, omissions and/or errors exist. Follows APA style and formatting guidelines for citations and references. Follows APA style and formatting guidelines for citations and references without errors or omissions.
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Clinical Decision Support Functions
Clinical Decision Support Functions
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Documentation Errors
Data Mining
Legal and Ethical Considerations
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Clinical Decision Support Functions
Now that you’ve explored the information, answer
these questions to assess your Clinical Decision
Support Functions knowledge.
Question 1 of 10:
True or False: The Clinical Decision Support System (CDSS) is one of
the most important reasons for documenting at the point of care.
True
False
Correct.
CDS systems assist clinicians with making decision about patient care. They
provide additional information by providing access to other documents, such as
the patient’s medical history and diagnostic testing results. They also provide
alerts to possible allergies and drug interactions.
Question 2 of 10:
True or False: Knowledge-based CDS systems consist of three
components.
True
False
Correct.
Knowledge-based CDS systems consist of four components: knowledge base,
production rules, inference engine, and user interface.
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Clinical Decision Support Functions
Question 3 of 10:
True or False: There are non-knowledge-based CDS systems that use a
form of artificial intelligence.
True
False
Correct.
Artificial intelligence allows computers to learn from past clinical data patterns.
The computer can learn from the physician’s past practices and make
recommendations for current care, such as suggestions about which diagnostic
tests to order.
Question 4 of 10:
True or False: CDS systems are rarely integrated with CPOE or EMAR
systems.
True
False
Incorrect.
CDS systems are frequently used with CPOE and EMAR systems to provide
information on potential drug contraindications.
Question 5 of 10:
True or False: CDS capabilities consist of six major categories:
medications, orders, alerts or reminders, relevant information, expert
systems, and workflow support.
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Clinical Decision Support Functions
True
False
Incorrect.
CDS capabilities consist of these six major categories: medications, orders,
alerts or reminders, relevant information, expert systems, and workflow support.
These six categories can be divided further into 53 unique features.
Question 6 of 10:
True or False: CDS systems are most effective when every possible
alert displays.
True
False
Incorrect.
Effective CDS systems tier alerts so that only the most important display.
Question 7 of 10:
True or False: CDS systems are most effective when the system
matches user intentions.
True
False
Incorrect.
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Clinical Decision Support Functions
When the CDS system matches user intentions, users are less likely to override
or ignore alerts.
Question 8 of 10:
True or False: Once in place, CDS systems do not require regular,
ongoing maintenance.
True
False
Correct.
CDS systems require regular, ongoing updating to remain current with best
practices within the health care field.
Question 9 of 10:
True or False: One concern about using CDS is that health care
providers will become dependent on the system.
True
False
Correct.
Because the CDS system alerts health care providers about drug allergies or
drug contraindications, health care providers could become dependent on these
alerts and not review the information on the record for additional allergies.
Likewise, they may not consider additional drug contraindications that may
occur.
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Question 10 of 10:
True or False: CDS software is subject to FDA regulation.
True
False
Incorrect.
CDS software allows health care providers to review the information and make
independent recommendations. The FDA’s contention is that health care
professionals will be able to come to the same decision with or without the
assistance of CDS software.
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