The Electronic Health Record Systems Policy

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Table of Contents

Analysis
EBP in EHR
Work Setting and Strategic Plan
Efficient Workflows, Interprofessional Care, and Patient Satisfaction
Policy
Guidelines
References

Analysis

It is important to note that electronic health record systems and related healthcare data collection instruments are highly effective tools, which can improve the nursing practice by assisting nursing professionals as well as improving patient outcomes. Therefore, relevant policies should be implemented in order to enhance the general process of nursing care, and the given assessment will primarily propose a policy for a specific situation, which is drug administration. The policy is based on making electronic health records or EHR systems a sole platform for drug administration, medication monitoring, treatment adherence, and substance abuse screening conducted by nursing professionals in order to advance the evidence-based practice or EBP into EHR.

EBP in EHR

One should be aware that there is a major need to integrate core EBP elements into EHR. It is stated that “delays in moving new EBP practice changes into the EHR are significant. These delays are sources of frustration and job dissatisfaction” (Chipps et al., 2020, p. 136). The same research also identifies that five themes, which act as a barrier for EBP and EHR merging, are EBP is not a primary goal, structure of an organization and its governance, EHR change prioritization, limited ability of nurses to change EHR, and delays and wait times (Chipps et al., 2020). In other words, the tool is not utilized to its fullest extent, and thus, the tool can be evaluated as poorly related to EBP, but giving more freedom to nurses can facilitate the merge.

Work Setting and Strategic Plan

The current work setting in EHR can also be evaluated as limited, where there are potential risks for patient safety, such as copy and paste practice. It is stated that “copy and paste can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart” (Lehmann et al., 2017, p. 12). In other words, the current EHR capabilities undermine the core principles of EBP, which can be even more problematic in regard to drug administration. In addition, EBP information used in drug administration is of paramount importance, and the current state of EHR is indicative of the fact that it is not realized to its fullest capability since nursing professionals can use EHR for all drug-related practices as well as evidence-based use of data, such as screening (Alemi et al., 2018).

Efficient Workflows, Interprofessional Care, and Patient Satisfaction

A thorough analysis of EHR reveals that there is a need for its optimization in order to improve workflows since many essential functions, especially for nurses, are poorly available or unavailable. For example, the copy and paste option is a prime example of how drug administration and recording can be prone to errors due to a lack of ways to identify which parts are copied and which are inserted manually (Lehmann et al., 2017). Interprofessional care can also be enhanced in order to improve, which is even more relevant in nursing since the communicative element of EHR is critical for promoting EBP principles of care, which can lead to better patient outcomes and satisfaction due to orderly and timely care delivery (McGonigle & Mastrian, 2018).

In conclusion, it is important to note that EHRs are highly useful tools, which can enhance a wide range of areas of nursing practice and care. However, the evidence suggests that there is a greater need for improvements in EHR in order for it to be able to promote and integrate EBP principles. The assessment specifically evaluated drug administration, which requires more functional features from EHR and policy changes since governance is among the main barriers for EBP’s incorporation into EHR.

Policy

Policy: Nursing professionals need to be able to use EHR systems alone in order to conduct drug administration, medication monitoring, treatment adherence, and substance abuse screening of patients since evidence suggests that it will move core EBP principles to EHR, which implies that there is a need for EHR functionality and communicative enhancement, and thus, these objectives require prioritization and need not to be secondary factors.

The evidence suggests that EHR change prioritization, organizational governance, and structure, as well as a limited impact of nursing professionals to be part of necessary changes to the EHR system, are the main barriers (Chipps et al., 2020). Therefore, it is of paramount importance to provide more freedom and influence to nursing professionals to be able to participate in the development and functional modifications to EHR in order to promote EBP through drug screening and interprofessional collaboration. Such a need for functional improvements are copy and paste identification functions, medication monitoring of a patient, drug incompatibility monitoring, substance abuse adherence monitoring, and drug screening (Lehmann et al., 2017). These changes will inevitably affect the workflow for the better by automatic many manual processes, which will eliminate or significantly reduce delays in care delivery, and the latter will have a strong effect on patient satisfaction improvements.

Guidelines

The proposed policy ought to be implemented on all organizational levels to all qualified nursing personnel who directly provide care to patients. The evidence is suggesting that “nurses, healthcare providers, and hospitals have been slow to adopt any comprehensive EHR. Potential barriers include a lack of computer skills, high cost, security concerns, workflow issues, and time” (Hoover, 2017, p. 9). Therefore, as direct care providers, nurses should be the ones who are involved in the full EHR improvement and adoption process. In order to advance core EBP principles, EHR system improvements need to be prioritized from a secondary rank to a primary one with the enablement of nursing professionals to have a functional role in directing these changes.

The functional EHR modifications in regards to drug administration need to focus on copy and paste identification functions, medication monitoring of a patient, drug incompatibility monitoring, substance abuse adherence monitoring, and drug screening (Lehmann et al., 2017). Thus, guidelines are to give nursing professionals specifically allocated time and resources to be involved in system incorporation and improvements. Interprofessional teams need to be assembled to generate these changes, with nurses taking on main managerial roles since modifications need to also be in accordance with EBP principles for improving patient outcomes and patient safety metrics of evaluation.

References

Alemi, F., Avramovic, S., & Schwartz, M. D. (2018). Electronic health record-based screening for substance abuse. Big Data, 6(3), 214–224. Web.

Chipps, E., Tucker, S., Labardee, R., Thomas, B., Weber, M., Gallagher‐Ford, L., & Melnyk, B. M. (2020). The impact of the electronic health record on moving new evidence‐based nursing practices forward. Worldviews on Evidence-Based Nursing, 17(2), 136–143. Web.

Hoover, R. (2017). Benefits of using an electronic health record. Nursing Critical Care, 12(1), 9–10. Web.

Lehmann, C., Michel, J., Solomon, R., Possanza, L., Gandhi, T., & Tsou, A. (2017). Safe practices for copy and paste in the EHR. Applied Clinical Informatics, 8(1), 12–34. Web.

McGonigle, D., & Mastrian, K. (2018). Nursing informatics and the foundation of knowledge (4^th ed.). Jones & Bartlett.

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