Assessment 2 Instructions: Importance of Accurate and Complete EHRs

Write a memo (1-page) 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.
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.

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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, then 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.
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10/30/22, 10:28 PM Assessment 2 Instructions: Importance of Accurate and Complete…
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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.
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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: APA Style and Format.