INFO-6060 – Electronic Health Records Lab #1 Answer the following questions for the lab, making sure to answer these DIRECTLY in the space provided using the default paragraph settings and format. Do not alter the Word document in any way. If this is not followed, there is an automatic mark of zero given. Use the PowerPoint slides and conduct any internet searches where required. Remember that a great paper will go above and beyond what I am asking with extra examples and external references added using APA format with the proper in-text citations. Otherwise, your lab will be marked out of 80% as a maximum mark. Use a separate page at the end of the lab labeled “References” to list your references. There are 5 extra marks allocated for having an external reference, grammar, etc. There are no word or page limits other than ensuring that you properly answer each of the questions, and no cover page is required. *** Any sign of plagiarism, use of banned websites and/or use of AI tools will be subject to an automatic mark of zero for the entire Lab, as well as an official academic penalty being issued (no warning). 1. During a transition from paper to EHR, you, as the role of Manager, must prepare a workflow to make this transition easier. Explain why a workflow analysis is required, including what this analysis should highlight, and, in bullet form, detail a transition plan for a group of employees to follow that will outline the steps to convert a paper record to an EHR record. (20 marks) Ans: Electronic Health Record is the systematic digital documentation of patient health information in the suitable and valid EHR tool. Me as a manager would implement the proper and effective workflow protocol for the easier transition of paper documentation to the EHR. Analysis of workflow determines how efficiently the work is being done. It is the review of the each and every steps of the specific operation. It is very crucial for the successful implement of any plan. Some of the major factors explaining the importance of workflow analysis are listed below: Transition from paper to EHR is a rigorous process which requires certain time and the workflow analysis helps to identify any loopholes or obstacle in smooth operation of the work. (Zheng et al., 2020). Workflow analysis facilitates the understanding of the current processes and relations. Understanding of these factors are crucial for a smooth operations. (Zheng et al., 2020). Workflow analysis helps to identify the roles and responsibilities of the user which ensures the successful implementation of the adopted procedures. (Zheng et al., 2020). Workflow analysis determines the specific place of misunderstanding and errors throughout the transition process, which enables to apply preventive actions to minimize them. (Zheng et al., 2020). In my view, the workflow analysis must highlight how the paper based documentation is carried out currently. It should identify the major stakeholders (physician, nurses, others healthcare provider) and INFO-6060 – Electronic Health Records acknowledge their roles in the workflow. It must analyze the process of relationships and proper circulation of the information. It should access the possibilities of enhancement opportunities of the procedures and also should determine the possible hurdles to the system. It should be aware about the present practices for documentation and storage of data. It must identify the key choices and interface of the workflow (Zheng et al., 2020). Hence, above mention points are the major factors that the workflow analysis must highlight. As Manager, I would implement following step-wise plans for the transition of a paper record to an EHR: Step I: Planning and Assessment: Initial step to carryout for the transition of paper document to EHR would be assessment and planning of how actually the work is to be done and preparing the layout of the implementation plan. (Wanga, 2023) Step II: Determination of specific EHR tool: After the proper planning and assessment, specific EHR tool should be identified and determined for the implementation process. It should be selected according to the requirement of the healthcare organization, as many options of EHR tools are available therefore proper tool must be selected by taking expert opinion and as per the need. (Wanga, 2023) Step III: Establishment of Policies and Procedures regarding EHR: Policies are made by the organization regarding the confidentiality of the patient data and data protection must be given the top priority in this step. Step IV: Installation of EHR Software: After establishment of proper rules and regulations, EHR software must be installed in the organization system wherever required for smooth operation. Step V: Provide training to the employees: After the installation of the software, employees who are responsible for its use must be trained properly about using the data base as any errors can lead to serious health consequences. (Wanga, 2023) Step VI: Practice hybrid documentation model parallelly for some period of time: The transition of all the paper documentation into electronic record is not possible promptly, therefore hybrid documentation model must also be carried out alongside for some instance. Step VII: Document all the paper record digitally: Simultaneously the paper record stored in the medical record department must be documented systematically in EHR. (Wanga, 2023) Step VIII: Destroy Paper record: After converting all the paper record digitally, the paper record are destroyed. (Wanga, 2023) Step IX: Maintain Continuous training: Since, now all the information are stored digitally it must be protected with high security, therefore regular update of the database/EHR tool must be done and employees must be given continuous training about the updates and new feature of the tools, which helps for smooth operation of the organization. (Wanga, 2023) INFO-6060 – Electronic Health Records 2. When giving a talk on best documentation practices for an EHR, the topic you chose to talk about is why you should look at a “Do Not Use List” when it comes to using abbreviations in an EHR. Explain why having a “Do Not Use List” is vitally important, what the implications are if you use an abbreviation that is on this list and a practical healthcare situation where one can see how this would actually happen (15 marks). Ans: Those abbreviations which may lead to the misinterpretation of the actual meaning of the word are listed as the “Do Not Use List” by different organization related to healthcare. These use of “Do Not Use List” acronyms in documentation practices for health record keeping may cause medication error and may led to serious health consequences. Few examples of how these list misleads the information are presented below: IU stands for “International Unit” but it is mistaken for “IV” (intravenous) or “10” (ten), instead use “unit”. (ISMP Canada, 2018). QD and QOD stands for “Every day” and “Every other day” respectively, but QD and QOD have been mistaken for each other therefore Use “daily” or “every other day”. (ISMP Canada, 2018). OS, OD and OU stands for “Left eye”, “Right eye” and “Both eyes” respectively, but may be confused with one another hence, use “Left eye”, “Right eye”” or “Both eyes”. (ISMP Canada, 2018). D/C stands for discharge but is misinterpreted as “discontinue whatever medication followed” instead use “Discharge”. (ISMP Canada, 2018). In my opinion, having a “Do Not Use List” for abbreviations in an EHR is vitally important for the following reasons: 1. For Patient Safety: Misleading abbreviations can cause diagnostic error, medication errors, or other adverse events. To ensure patient safety and effective healthcare documentation and delivery, clear and standardized communication is important. The primary concern is patient safety therefore, all the healthcare professionals involved in a patient's care must understand and interpret the information correctly. (Tariq, 2023). 2. To Minimize Various Medical Errors: The use of inappropriate abbreviations can cause the risk of miscommunication or misunderstanding, potentially resulting in medical errors. As tabulated above, certain abbreviations seems similar or possess multiple meanings, leading to confusion among healthcare professionals and hinders patient safety. (Tariq, 2023). 3. Adherence to Law: If the healthcare organization follows the "Do Not Use List" then the organization adhere with the regulatory standard set by the accrediting bodies of healthcare. Due to which patient safety is prioritized. (Tariq, 2023). Use of an inappropriate abbreviations from the list may hamper directly to the patient in the practical healthcare situation in many ways. Let us assume that, a healthcare professional is recording a data (patient's details) in the EHR using an abbreviation that is on the "Do Not Use List." The acronym used, however, means different meaning then what it actually is. For example, if it alters the dose/frequency of medication then the nursing practitioner following the instruction from INFO-6060 – Electronic Health Records EHR can administer completely different dose/frequency of medication to the patient. Due to which following consequences might occur: The patient may not be therapeutically benefited from the treatment given or may experience adverse effects. The organization or healthcare provider could face legal consequences for malpractice. It may even be fatal to the patient. Hence, avoiding "Do Not Use List" for abbreviations in the documentation of EHR is crucial for safe guarding patient health and to minimize medical errors. 3. What are the four levels of interoperability and fully explain each level of interoperability when it comes to exchanging data in EHR systems (20 marks). Ans: The capability of two (or more) systems or components to communicate and make use of the information they have exchanged is known as interoperability. Interoperability are generally categorized into four different levels which are listed below: 1. 2. 3. 4. Foundational Interoperability Structural Interoperability Semantic Interoperability and Organization Interoperability Foundational Interoperability: This level of interoperability allows two (or more) systems to exchange data between them but does not allow them to process beyond that (Rezaei et al., 2014). Since, the transferred data cannot be interpreted by the IT systems, it is the basic levels of interoperability. The prerequisites for safely exchanging data and connecting multiple systems were established at the Foundational level (Mello et al., 2022). This level is limited to accepting incoming data and confirming receipt of the data. For health care organizations, this is a useful starting point since it provides the foundation for higher levels of interoperability. Lower level of interoperability can be achieved by hospitals and health care organizations by establishing the foundation for future improvement in the exchange of health data by utilizing the current standards for health data. (EHR Intelligence, 2022). Structural Interoperability: This level of interoperability is characterized by the capacity of the systems for data interchange and interpretation. Data formats are typically exchanged and the structure of data are organized so that the recipient can recognize the incoming data and analyze it. Structural interoperability is essential for various healthcare organizations including clinics, pharmacies, labs etc to share health information efficiently and effectively (Rezaei et al., 2014). To ensure that information is consistently understood and interpreted by diverse systems, it requires standardizing the organization, formatting, and transmission of data. Structural interoperability in healthcare is greatly aided by common data standards and formats as Health Level Seven International (HL7) and Fast Healthcare Interoperability Resources (FHIR). (Jiang et al., 2016). INFO-6060 – Electronic Health Records Semantic Interoperability: This level of interoperability is defined as the capacity of the recipient system to manipulate the data in accordance with defined meanings. Semantic interoperability typically refers to the definition of content and deals with how humans interpret it as opposed to machines. It addresses the shared meaning of the data in addition to structural interoperability, which makes sure that data can be transferred in a consistent way. In the healthcare industry this level of interoperability uses the standardized vocabularies, terminologies, and abbreviations to guarantee that data is not only transferred in a standard format but also consistently interpreted and understood by various systems. Therefore, at this degree of interoperability, there is a shared understanding among individuals about the meaning of the information being exchanged (Jiang et al., 2016). Organizational Interoperability: The ability of organizations to successfully share and exchange of significant data/information over a wide range of infrastructure types and information systems, possibly across multiple geographic regions and cultural contexts is known as organizational interoperability. Successful other levels of interoperability are a prerequisite for organizational interoperability. It involves several elements such as standard of data ownership, data security measures and policies related to the data (Rezaei et al., 2014). INFO-6060 – Electronic Health Records References: Zheng, K., Ratwani, R. M., & Adler-Milstein, J. (2020). Studying Workflow and Workarounds in Electronic Health Record-Supported Work to Improve Health System Performance. Annals of internal medicine, 172(11 Suppl), S116–S122. https://doi.org/10.7326/M19-0871 Wanga, E. O. (2023, August 3). How to Go From Paper to Electronic Records in 7 Steps. Experience Care: Long-Term Care EHR & Financial Software Solutions. https://experience.care/blog/from-paper-toelectronic-records-in-7-steps/ Institute for Safe Medication Practices Canada. (2018, June). Dangerous Abbreviations, Symbols and Dose Designations. https://www.ismpcanada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf Tariq, R. A. (2023, May 22). Inappropriate Medical Abbreviations. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK519006/ Mello, B., Rigo, S. J., Da Costa, C. A., Da Rosa Righi, R., Donida, B., Bez, M. R., & Schunke, L. C. (2022, January 26). Semantic interoperability in health records standards: a systematic literature review. Health and Technology. https://doi.org/10.1007/s12553-022-00639-w EHR Intelligence. (2022, May 2). How health data standards support healthcare interoperability. https://ehrintelligence.com/features/how-health-data-standards-support-healthcareinteroperability#:~:text=According%20to%20HIMSS%2C%20interoperability%20%E2%80%9Cdescribes% 20the%20extent%20to,that%20it%20can%20be%20understood%20by%20a%20user.%E2%80%9D Rezaei, R., Chiew, T. K., Lee, S. P., & Aliee, Z. S. (2014, January 1). Interoperability evaluation models: A systematic review. Computers in Industry. https://doi.org/10.1016/j.compind.2013.09.001 Jiang, G., Solbrig, H. R., Chute, C. G., & Tao, C. (2016). Knowledge representation of observational data in health care–The common data model (CDM) and its implementation in OHDSI. Journal of Biomedical Informatics, 64, 118-129.
