The healthcare system is an information-rich environment. It is a complex, diverse, knowledge-intensive discipline with the available knowledge being revised and extended regularly. Information in the healthcare system extends beyond clinical care to areas of finance and management. The American healthcare system is highly dependent on healthcare informatics. Health information system (HIS) is utilized in collecting, processing, storing, and transferring information to aid planning and decision making in different levels of the hospital. HIS improves quality, efficiency, and safety in healthcare enabling the organization to offer quality services. Whereas HIS is beneficial to the healthcare organization, there are many factors to put into consideration during the adoption. Issues of clinical quality and safety, privacy and security, Health IT resources, training, and laws and regulation regarding health IT needs to be addressed. The purpose of this paper is to analyze the healthcare informatics system (HIS) and its impact on nursing practice.
Clinical Environment
Valley Hospital* provides inpatient, outpatient, diagnostic imaging, medical, surgical, and emergency services to the local community. The hospital was established in 1997, and it has grown in capacity. The hospital has 321 beds, and the healthcare complex is continually expanding and taking advantage of the latest technology to deliver care.
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The hospital began incorporating health information systems (HIS) in 2016 to address some of the pressing problems, including delays in inpatient discharge, medical errors, and dwindling cash flow. The administration wanted a system that would enable all the units can have real-time access to patient information. Once the patient has passed by the emergency department and taken for tests, all the other units can access the information to minimize errors. HIS also improved efficiency in the hospital by streamlining processes in the healthcare facility. HIS enable nurses to keep up with new developments while reminding them to attend to their patients.
The implementation of HIS has proven to a long and costly journey for the hospital. The hospital has eight units, and designing a HIS system that takes into consideration the needs of all the departments was a challenge. The hospital began the use of HIS in the emergency department as it progresses to the other units. The transition to electronic health records is expensive as the hospital had to invest in training, technology, and managing the implementation process. Some physicians and nurses are not open to the new technology as it will influence their already established routines. HIS changes the nursing practice through the new approaches to documentation, communication, and collaboration with other clinicians. Nurses no longer rely on paper charts and handwritten notes; instead, they refer to notes within the electronic records and other patient medical history systems. The organization is yet to achieve full implementation of HIS because of many challenges in implementation. However, the organization is experiencing benefits in the three units that have implemented it. Communication between nurses and physicians has improved in the three departments, translating to improved patient outcomes. Patients are no longer complaining about the delays in discharge as health informatics facilitates smooth and efficient documentation.
Significance
Health informatics is concerned with the use of information and communication technologies in the healthcare system. Therefore, health informatics must take into account the unique aspects of health (Nguyen et al., 2014 p.783). Health informatics is supposed to improve information gathering, sharing, and storage; thus, it must take into consideration the information needs and behaviors of all users. Nguyen et al. (2014 p.784) state that HIS design should be user-friendly from the planning to the implementation stage. Designers have to take into consideration the impact on workflow. User involvement is an approach that can be used to increase the user-friendliness of the HIS. Designers should seek user input from the planning and design stage as user involvement is beneficial. When users are involved, the designers will gather accurate information that will enable them to create useful features (Nguyen et al., 2014 p.785). Additionally, there is a higher level of user acceptance during implementation when users are involved in the planning and design phase. Health facilities that use a user-centered approach to design decrease the training needs as the users already have an increased understanding of the system.
Another significant issue affecting health care informatics is stakeholder involvement in the implementation of HIS. Grossman & Valiga (2016, p. 125) state that nurses are full partners with physicians and other health professionals, and they should be involved in the organizational change process. While some users are involved in product testing, they should also be involved in the project implementation process for the success of the project. Nurses are less likely to support the HIS when only the physicians are consulted and involved during the implementation. Stakeholder involvement can be in the form of communication and training. The management should communicate about the adoption of HIS to nursing and clarify their concerns.
Training is another critical issue to consider during the implementation of HIS. According to Darvish et al. (2014 p.11), HIS requires nurses to learn new competencies. Nurses have to learn computer skills for retrieving patient documentation and using technology safely to avoid confidentiality and privacy issues. Nurses also require training in informatics skills. Nurses should have knowledge on how to interpret the information flow, preparing flow charts and database structures for evaluation and administrative purposes. HIS avails a breadth of nursing information, which can be used as the basis of nursing research. Without information literacy skills and competencies, nurses cannot take advantage of the information to identify patterns and solutions to existing patient problems within the organization.
Lastly, privacy and confidentiality concerns are significant issues affecting the implementation of HIS. Healthcare professionals have a legal obligation to protect patient health information confidentiality, and privacy (Darvish et al., 2014 p.12). With HIS, protecting patient confidentiality and privacy is challenging as physicians share information with nurses, other clinicians, managers, and finance and insurance personnel, among other individuals with vested interests. Nurses have to respect patient autonomy such that patients are in charge of their health information. Disclosure should be guided by the principles of beneficence and non-maleficence (Sittig & Singh, 2015 p.62). The Health Insurance Portability and Accountability Act (HIPAA) came up with security requirements for institutions and clinicians using HIS. Nurses should be educated on the issue of privacy and confidentiality as well as the security techniques for safeguarding patient information.
Analysis
The health informatics system is a network of computer hardware and software technologies. When clinicians use these technologies, they generate new information that can affect operations and decision making. The design of the HIS should be effective to enable the proper flow of information. Sittig & Singh (2015 p.63) add that the design of health IT should take into consideration the people, processes, and environment. The system should be designed in a way that it supports the user goals and workflows. Thus, organizations should first implement the systems in departments that interact with the patients.
According to Sittig & Singh (2015 p.64), the organization should adopt a proactive model to meet the needs of patients, clinicians, and organizations. The system should make it hard to make errors such that a patient suffering from a particular condition should not be prescribed the wrong medication because the system does not allow it. The model should be data-driven to minimize errors and enhance interdepartmental efficiency. The Agency for Healthcare Research and Quality (AHRQ) adds that organizations should take into consideration the workflow when implementing HIS. Workflow is the sequence of tasks performed by clinicians and other personnel in the hospital. Workflow can occur at several levels or sequentially, and in some cases, it coincides. For example, when a doctor writes a prescription to the patient by entering it to the electronic prescription, it is transmitted directly to the pharmacy. This is an example of how a task can occur simultaneously.
The HIS has to take into consideration the workflow during the planning and implementation. Failure to analyze the workflow often leads to delay in patient care, billing, and communication leading to poor health outcomes (AHRQ, n.d). The workflow should not be overlooked or oversimplified as it will bring more problems in the future. AHRQ gives a workflow tool that takes into consideration the sequential stages of determining system requirements, selecting a vendor, preparing for implementation, and using the system post-implementation (AHRQ). In each step, there are job tasks and system requirements that must be taken into consideration. The workflow will determine the design of the HIS and where to start the implementation process.
There are different workflow tools, including benchmarking, checklist, flowchart, and interview and usability evaluation. Each workflow tool operates differently; for instance, a flowchart visually conveys the steps in a process while an interview elicits information from a group of individuals on their behavior, opinion, and knowledge. Benchmarking is about identifying and evaluating metrics or the best practices in each department, organization, or other organizations and applying them to the implementation of HIS ( Kim, Coiera & Magrabi, 2017 p.247) . Benchmarking leads to the creation of innovative solutions to problems and the creation of attainable goals that can improve performance (AHRQ n.d). However, it requires a long-term commitment. Like interviews, benchmarking will identify much information that might not be meaningful to the HIS implementation process. Additionally, competitors might not share information freely.
A checklist is a preferred tool for designers as it displays the collected data in a familiar and visual format. A checklist is also easy to use and simple to create, and it determines the specific frequency of tasks. Nonetheless, checklists tend to be extremely specific to a particular situation. Sittig & Singh (2015 p.76) suggest that organizations should use different workflow tools to identify different perspectives to guide the implementation of health IT. Each workflow tool has its advantages and disadvantages that can affect the design and implementation of HIS.
Implications for Practice
HIS issues significantly impact the health care setting and nursing practice. HIS yields useful data while enhancing clinical processes to maximize efficiency and improve patient outcomes (Lavin, Harper & Barr, 2015 p. 14). Hospitals and clinicians have welcomed HIS, but they also have expressed their dissatisfaction with some of the HIS issues, from design, privacy and safety concerns, medication safety, documentation and standards of practice, and HIS efficiency.
According to Lavin, Harper & Barr (2015 p. 15), HIS has exceptional attention to medication safety, particularly the prevention of errors in prescription, transcribing, and dispensing. Studies on HIS and electronic health records show that technology adoption has drastically reduced medication errors as the medication data is already contained in the electronic system. However, there is a need to create a system that is sensitive to nurse-patient interactions. Nurses are the individuals who interact with patients more, and there should be strategically placed tips and alerts to make the process more flexible and free of errors. Lavin et al. (2015 p.17), there is a need to improve the user-friendliness of the HIS through efficient and timely access to lab tests and medication to guide nursing strategies.
The issue of documentation and standards of practice requires the adoption of standardized processes for the HIS. HIS is used to support evidence-based care processes through the provision of patient educational materials and action plans for nurses ( Kim, Coiera & Magrabi, 2017 p. 248) . Therefore, nurses should possess the skills to make sense of standardized processes and products. When nurses use their own material and knowledge, they will not meet the appropriate patient education/health promotion standards.
HIS facilitates documentation, which is a form of clinical decision support system (CDSS). CDSS tools sift through enormous amounts of data to guide the next steps of treatment. CDSS tools are integrated into the HIS to streamline the flow of data and create intuitive, user-friendly protocols of alarms and alerts to facilitate decision making (Sittig & Singh, 2015 p.69). CDSS focuses on condition-specific order sets, patient-focused information including reports, summaries, documentation, and diagnostic support. CDSS provides the right information through the right channels and intervention formats to facilitate decision making.
The concept of interoperability also has implications on CDSS and the health information exchange (HIE). Interoperability refers to the ability of HIS to work together within the organization and across organizational boundaries. The HIS must possess the ability to exchange data with other systems such that tests and diagnostics can share information with other departments easily. Interoperability can be structural or semantic, depending on the system in place (Lavin et al., 2015, p. 16). Semantic interoperability is the best option as it enables multiple systems to use and exchange data across disparate systems.
Organizations must be aware of the legislation guidelines and laws, such as HITECH. HITECH Act of 2009 widened the scope of privacy and security protections under HIPAA compliance. Health providers that fail to implement the rules and regulations increase their legal liability. HIPPA came up with the Privacy Rule, which mandates health care providers to seek patient consent before sharing patient health information with other parties (Darvish et al., 2014, p. 11). There are many other rules and regulations that the health organization must observe.
Lastly, issues with the development of the workflow have negative implications for the organization and nursing practice. Aforementioned, there are many workflow toolkits, yet organizations often limit themselves to one or two toolkits. The toolkits establish the nursing process steps while describing and prioritizing individual problems from admission, transfer, and discharge. The appropriate workflow model will make nursing more responsive to patient needs. It will lead to timely and effective nursing documentation that can be used to provide adequate service across the continuum of care. However, an inefficient workflow within the HIS will lead to errors, inefficiencies, and adverse health outcomes.
Conclusion
The implementation of the health information system remains a challenge for health organizations. Even with the availability of a great deal of scientific knowledge, much needs to be done to achieve effective implementation. The implementation of HIS is the organization unearths the challenges of safety concerns, technical issues, workflow challenges, and the need for more staff training. HIS cannot address organizational deficiencies, including errors and poor documentation unless the organization takes time to develop documentation and informatics skills. The proper design and implementation of HIS starts with the identification of all user/organization need to be taken into consideration. The management should rely on proper project planning and implementation skills to support the HIS. This involves involving health workers across all levels, which will result in better adoption of health technology. As organizations continue to adopt health technology, there is a need to evaluate if the technology is improving safety and patient outcomes. Once the organizations realize the potential returns on HIS, addressing the challenges/issues associated with the implementation of HIS will become a priority. The organization should engage in research on how to enhance user involvement in system development and dissemination of information to increase the success of future HIT projects.
References
Agency for Healthcare Research & Quality. (n.d.). Health Information Technology: Best Practices Transforming Quality, Safety, and Efficiency. Retrieved from: https://healthit.ahrq.gov/
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Lavin, M. A., Harper, E., & Barr, N. (2015). Health information technology, patient safety, and professional nursing care documentation in acute care settings. Online J Issues Nurs , 20 (2).
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Sittig, D. F., & Singh, H. (2015). A new socio-technical model for studying health information technology in complex adaptive healthcare systems. In Cognitive informatics for biomedicine (pp. 59-80). Springer, Cham.
