Description
Write a one-page memo to a HIM director explaining data entry inaccuracies and deficiencies in the EHR system that potentially impact clinical care. Include an explanation of the findings and their importance. Provide evidence-based recommendations to address identified issues. Provide EHR Go supporting activities as attachments to the memo.
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Introduction
A range of decision support models can serve as the basis for a clinical decision support system. Rules-based systems are effective in helping users make yes-or-no decisions. More complex decision types require more complex methodologies. Recognizing the relationship between decision support models and CDS systems is critical to making sound decisions about how to apply a CDS to accomplish a particular result. To appropriately interpret CDS system results, system users need to be able to see the big picture. They need to understand the concepts underlying CDS systems.
Given the high degree of user resistance, selecting a clinical decision support system is often a& challenging task. The frequency with which IT projects fail has been the subject of much research and speculation. The same holds true for clinical decision support systems. The evidence-based health care industry places a high value on using clinical data to identify best practices and high-quality clinical outcomes. At the same time, putting a CDS system into practice is far more difficult than it would appear. Many CDS system implementation issues are specific to system users. For example, some CDS systems support the work of physicians. These individuals may not be open to accepting guidance from an unknown—and in their eyes unproven—expert system. In fact, evidence shows a high rate of physicians reject CDS system advice in favor of the physician’s professional experience and preferences.
The health care industry has come to understand how critical user acceptance is to successful CDS implementations. The advantages of system implementation are reduced or eliminated when users do not use the system or do not use it properly. CDS systems require significant input from the clinical staff, who generally are busy. When clinical staff are not excited about embracing the system and prepared to invest time in making it successful, clinical managers must step in. They must dedicate staff to closely monitor the accuracy and integrity of the system’s expert advice.
In this second course assessment, as a data analyst, you will have the opportunity to do just that: monitor the CDS system’s advice for accuracy and integrity. During the course of your work you regularly review and correct information contained within the system. You know that incorrect information in the system can literally have life-or-death consequences for patients. You want to bring to your boss’s attention the volume and type of incorrect information you’re seeing. Your plan is to write a memo to the HIM director about your findings and their importance. You also know that your boss will appreciate your recommendations for resolving the issues you’re uncovering.
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.
Explain the benefits and risks associated with CDS systems.
Competency 3: Apply common performance improvement models.
Recommend evidence-based strategies for maximizing the benefits and minimizing the risks associated with CDS systems.
Competency 4: Apply data extraction methodologies.
Edit patient information accurately.
Explain how editing patient information affects data extraction for CDS.
Recognize incomplete or missing data in the patient chart.
Explain how chart inaccuracies impact patient care and clinical decision making.
Competency 6: Communicate effectively in a professional manner.
Write a clear, well-organized, professional memo that is 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
The first step in completing this assessment is to do the two assigned EHR course activities. You will be submitting these as attachments to a memo you are going to write to the HIM director about inaccuracies and deficiencies you’ve identified in the EHR system. The work you complete in the EHR Go activities will inform what information you include in your memo.
In the first activity, you will practice editing patient information. You will also reflect on the implications of errors on the availability of patient data for clinical decision support.
EHR Go: Editing and Extracting Patient Data.
In the second activity, you will review in detail data in a patient chart. You will use critical thinking skills to determine what is present, deficient, incorrect, or incomplete in the chart.
EHR Go: Record Deficiencies.
Here is the background information you need to complete the second part of your assessment. Your facility has recently implemented an EHR system. As a data analyst, you have been reviewing and correcting information within the system and identifying multiple deficiencies. You know that it is your responsibility to bring the amount and type of incorrect information to your boss’s attention. You have decided to create a one-page memo that:
Explains your findings.
Describes the importance of these findings.
Makes evidence-based recommendations for improvements.
Keeping your memo to one page may not seem long. It is, however, the reality in today’s health care workplace. It’s unlikely that busy executives will read more than a one-page memo—if that. You will need to be highly selective and include only the most critical information.
You will include the reports from the EHR activities as attachments to your memo.
Note: Your boss always wants to know the source of your information. Be sure to cite your sources and include a separate reference page with your memo.
Additional Requirements
Length: One-page (maximum) document in memo format.
EHR Go activities: Download and submit your two EHR Go activities for this assessment as attachments to your memo.
Writing: Create a clear, well-organized, professional memo that is 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 refresher on APA style and formatting guidelines: Evidence and APA.
Importance of Accurate and Complete EHRs Scoring Guide
CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Explain the benefits and risks associated with CDS systems. Does not explain the benefits and risks associated with CDS systems. Explains the benefits and risks associated with CDS systems in minimal depth and detail. Explains the benefits and risks associated with CDS systems. Explains the benefits and risk associated with CDS systems. Substantiates explanation with multiple examples and references to current, scholarly and/or authoritative sources.
Recommend evidence-based strategies for maximizing the benefits and minimizing the risks associated with CDS systems. Does not recommend evidence-based strategies for maximizing the benefits and minimizing the risks associated with CDS systems. Attempts to recommend strategies for maximizing the benefits and minimizing the risks associated with CDS systems. However, strategies are not always evidence-based or effective in addressing the identified issues. Recommends evidence-based strategies for maximizing the benefits and minimizing the risks associated with CDS systems. Recommends multiple evidence-based strategies for maximizing the benefits and minimizing the risks associated with CDS systems. Substantiates recommendations with examples and references to current, scholarly and/or authoritative sources.
Edit patient information accurately. Does not edit patient information accurately. Attempts to edit patient information accurately; however, omissions and/or errors exist. Edits patient information accurately. Edits patient information without errors or omissions.
Explain how editing patient information affects data extraction for CDS. Does not explain how editing patient information affects data extraction for CDS. Explains how editing patient information affects data extraction for CDS in minimal depth and detail. Explains how editing patient information affects data extraction for CDS. Explains how editing patient information affects data extraction for CDS. Explanation includes multiple examples and references to current, scholarly and/or authoritative sources.
Recognize incomplete or missing data in the patient chart. Does not recognize incomplete or missing data in the patient chart. Attempts to recognize incomplete or missing data in the patient chart; however, omissions and/or errors exist. Recognizes incomplete or missing data in the patient chart. Recognizes incomplete or missing data in the patient chart. Documents problems with the chart.
Explain how chart inaccuracies impact patient care and clinical decision making. Does not explain how chart inaccuracies impact patient care and clinical decision making. Explains how chart inaccuracies impact patient care and clinical decision making in minimal depth and detail. Explains how chart inaccuracies impact patient care and clinical decision making. Explains how chart inaccuracies impact patient care and clinical decision making. Explanation includes multiple examples and references to current, scholarly, and/or authoritative sources.
Write a clear, well organized, professional memo that is generally free of errors in grammar, punctuation, and spelling. Does not write a clear, well organized, professional memo that is generally free of errors in grammar, punctuation, and spelling. Attempts to write a clear, well organized, professional memo that is generally free of errors in grammar, punctuation, and spelling. However, lapses, omissions, and/or errors exist. Writes a clear, well organized, professional memo that is generally free of errors in grammar, punctuation, and spelling. Writes a clear, well organized, professional, and error-free memo. Memo includes 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.
