NR 515 Week 8 Informatics Synthesis Paper Example

Informatics Synthesis: Our Practice's Exchange Problems Are Problems of Custody and Standing Cost, Not a Product We Failed to Buy, and What to Fund Instead

Student Name

College of Nursing, Chamberlain University

NR 515: Informatics in Healthcare

Instructor Name

Month Day, Year

Informatics Synthesis: Our Practice's Exchange Problems Are Problems of Custody and Standing Cost, Not a Product We Failed to Buy, and What to Fund Instead

Thesis

Our six-provider family practice does not need a new platform to fix the way information moves between it and the organizations around it. It needs three things it has never had: a named owner for every route by which information enters the practice, monitoring funded as a standing cost rather than an afterthought, and a rule that no new electronic link is approved unless its second-year cost is budgeted along with its build. This paper argues for that recommendation using the work of this course as evidence, reads it from the side of each person who would have to approve it, and answers the strongest alternative, joining the regional hospital's shared EHR.

Sittig and Singh (2010) proposed that health information technology be understood through eight interacting dimensions, only two of which are hardware and software. Every problem found this term sat in the others: workflow, organizational policy, people and measurement.

The Evidence From This Term

Custody. The first assignment traced one echocardiogram report and found that it was missing from our record because it belonged to the hospital, which released it through a portal, a phone call and a fax. The report was not lost; it was held by another custodian, and retrieving it cost 22 minutes of nursing time and two hours of elapsed time. Retrieval is a transaction with another party, not a search.

Ownership. The system inventory walked one cardiology referral through eight systems and found that the only complete view of referral status lived in a spreadsheet kept by one person, with no owner in any job description. When she was on leave, nobody knew which referrals had closed.

Display. The data exchange analysis followed a potassium result and found that a hemolysis comment had arrived intact in our system but was not shown on the physician's inbox line or in the patient's app. No system failed; a display choice and a mapping choice did. Lippi et al. (2008) identified hemolysis as the leading cause of unsuitable laboratory specimens, so this is not a rare comment to lose.

Monitoring. The interface failure brief reconstructed nine days in which reference laboratory results stopped arriving. The vendor watched its engine, the laboratory watched its acknowledgments, and our practice watched nothing. A nurse found the gap by chance.

Constraint. The standards comparison judged a move to FHIR against our one part-time analyst and concluded that the older standard is safer for us for now, because most of what went wrong would have gone wrong under either standard.

The route. The referral map showed that about 50 of 59 days in a referral are spent waiting, and that two legs, the specialist's scheduling call to the patient and the return of the consultation note, have no owner at all.

Read together, these findings share one feature. In every case, the technology did what it was designed to do. What was missing was a person responsible for noticing when information did not arrive or did not show.

The Recommendation in Detail

1. A named owner for every inbound route. The inventory lists eight systems. Each route through which information reaches the practice, laboratory results, hospital documents, consultation notes, insurer decisions and patient messages, should have one named owner and one backup, recorded in a short policy. The owner is not expected to fix every problem, only to know within a day when the route stops working and whom to call.

2. Monitoring as a standing cost. Every route gets a simple, regular count: results received against specimens sent, consultation notes received against appointment dates passed. These counts take minutes a day and would have caught the nine-day stoppage on day 2. Their cost should appear in the budget every year, in the same way as the EHR subscription.

3. A second-year rule for new links. The integration proposal for cardiology notes quoted a build cost of $3,900 and a second-year cost of about $1,600 plus two hours of staff time a week. The rule is that a link is approved only if both costs are approved together, with owners named for the ongoing work.

Callen et al. (2012) concluded from their review of test result follow-up that solutions must include clear policies about responsibility as well as supporting technology. This recommendation puts the policy first and adds technology only where someone is funded to keep it working.

Read From Each Approver's Side

The medical director will ask whether this improves patient safety. The answer is that it addresses the specific near-misses found this term: a high INR unknown for three days, a potassium result that sent a patient to an emergency department unnecessarily, and referrals that could stall invisibly. It does not promise to prevent every error.

The practice administrator will ask what it costs. Owners and monitoring cost staff time, estimated at three to four hours a week across the practice, and the vendor alert may carry a small fee. The cardiology link is the only new capital cost, and it comes with its own business case. Against that sits the cost of a single serious missed result.

The referral coordinator, who would own several routes, will ask whether this simply adds to her work. It partly does. The recommendation removes one task, indexing faxed consultation notes, if the cardiology link is approved, and it replaces the private spreadsheet with status recorded in the EHR, where others can see and share the work. Her backup is named so that her leave no longer stops the process.

The Strongest Alternative

The strongest alternative is to join the regional hospital's offer to extend its EHR to community practices. Many hospitals offer such arrangements, and the appeal is obvious: hospital documents, results and some specialist notes would be in the same system, and several of the routes this paper worries about would disappear.

The argument deserves weight, and for some practices it is right. For ours, it fails on three counts. First, it would move custody, not remove the need for it; our records would sit in another organization's system under its policies. Second, it would not reach the independent cardiology group or our reference laboratory, which are not part of the hospital. Third, the transition would consume the analyst time and staff attention that the practice does not have, for a benefit that would still require owners and monitoring for every route outside the hospital. Mehrotra et al. (2011) found breakdowns in every part of the referral process across many settings, which suggests that no single platform removes the need to manage the handoffs between organizations. Patel et al. (2018), studying a large integrated health system, still found that only about a third of referral scheduling attempts ended in a documented completed appointment.

What Follows

If the recommendation is accepted, the first month's work is small: a one-page policy naming owners and backups, a daily laboratory count, a weekly consultation note count and the inbox comment indicator turned on. The cardiology link follows if its proposal is approved. The practice should revisit FHIR-based exchange in a year, as the standards comparison suggested, when federal expectations for standardized interfaces (Office of the National Coordinator for Health Information Technology, 2020) and our vendor's offerings have both moved further.

The larger point is that a small practice can manage its information exchange well without an informatics department, provided it treats every route as something someone owns and pays to watch.

References

Callen, J. L., Westbrook, J. I., Georgiou, A., & Li, J. (2012). Failure to follow-up test results for ambulatory patients: A systematic review. Journal of General Internal Medicine, 27(10), 1334-1348. https://doi.org/10.1007/s11606-011-1949-5

Lippi, G., Blanckaert, N., Bonini, P., Green, S., Kitchen, S., Palicka, V., Vassault, A. J., & Plebani, M. (2008). Haemolysis: An overview of the leading cause of unsuitable specimens in clinical laboratories. Clinical Chemistry and Laboratory Medicine, 46(6), 764-772. https://doi.org/10.1515/CCLM.2008.170

Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: Specialty referrals in the United States. The Milbank Quarterly, 89(1), 39-68. https://doi.org/10.1111/j.1468-0009.2011.00619.x

Office of the National Coordinator for Health Information Technology. (2020, May 1). 21st Century Cures Act: Interoperability, information blocking, and the ONC Health IT Certification Program. Federal Register, 85, 25642-25961. https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it-certification

Patel, M. P., Schettini, P., O'Leary, C. P., Bosworth, H. B., Anderson, J. B., & Shah, K. P. (2018). Closing the referral loop: An analysis of primary care referrals to specialists in a large health system. Journal of General Internal Medicine, 33(5), 715-721. https://doi.org/10.1007/s11606-018-4392-z

Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl. 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085