Standards, Regulations, and Policies- Executive Summary on Electronic Health Record EHR

September 14, 2024September 14, 2024 Discipline: Nursing

  • Select one of the data quality concepts (consistency, accuracy, completeness, relevance, validity, timeliness, and consistency) from the Quality Data Model (QDM) that you believe is problematic in EHR documentation.  
  • Select 2 standards, regulations, or policies that are influenced by this problem with EHR documentation.   
  • Briefly describe their relationship to MIPS and how these 2 standards, regulations, or policies might be influenced by this problem.  
  • Also, describe the impact that the problem with EHR documentation may have on healthcare providers and patient outcomes.  
  • Make 2 recommendations for addressing this problem.  
  • Use the literature and research to support the relationship of the problem to the standard, etc., and your recommendations.  You are not required to describe any technical aspects, only workflow or process improvement actions that may be used to deliver safe and high-quality patient care.
Sources

Meaningful Use for Promoting Interoperability in EHRs

         ADSC blog on Meaningful Use

         Incentive programs for EHR meaningful use

  • A concise overview of the evolution of Meaningful Use
Centers for Medicare & Medicaid Services [CMS]. (2018, May 4).  MACRA:  What’s MACRA?  Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html 
  • Some of this may be familiar with your health policy course
The Office of the National Coordinator for Health Information Technology (ONC), HealthIT. (2018, March 16). Meaningful Use and MACRA.  Retrieved from https://www.healthit.gov/topic/meaningful-use-and-macra/meaningful-use-and-macra    
  • Information about the CMS changes in the context of informatics  

Personal Health Records and the HIPAA Privacy Rule, Privacy & Security Policy HealthIt.gov. (2016). Retrieved from Personal Health Records and the HIPAA Privacy Rule, Privacy & Security Policy.

American Health Information Management Association. (December 6, 2018). MACRA/Quality Payment Program in 2019: Finalized Changes. Journal of the AHIMA, Retrieved from https://journal.ahima.org/macra-quality-payment-program-in-2019-finalized-changes/



Information on Standardized Nursing Terminologies

American Nurses Association [ANA]. (2018).  Inclusion of recognized terminologies supporting nursing practice within electronic health records and other health information technology solutions.  ANA Position Statement.

The Office of the National Coordinator for Health Information Technology. (2017). Standardized Nursing Terminologies: A landscape analysis. MBL Technologies, Clinovations.


U.S. National Library of Medicine. (2017). Nursing Resources for Standards and Interoperability. Retrieved from https://www.nlm.nih.gov/research/umls/Snomed/nursing_terminology_resources.html    Brief reading but with a special focus on SNOMED and LOINC with reference to international nursing work on standards. SNOMED and LOINC are the most robust standards currently, and the ones most applicable to nursing’s language development.






Internet Exploration


  1. Office of The National Coordinator for Health Information Technology (ONC) and HealthIT.gov website.
  2. Centers for Medicare & Medicaid Services (CMS), in particular Council for Technology and Innovation and Certified EHR technology
  3. Health Information and Management Systems Society. (2018). Health IT Public Policy. Retrieved from http://www.himss.org/library/health-it-policy
  4. HealthIT.gov website for The Office of the National Coordinator for Health Information Technology (ONC)






McQuade-Jones, B., Murphy, J., Novak, T., &, Sarnowski, L. (2014).  Nurse Practitioners and Meaningful Use: Transforming health care.  The Journal of Nurse Practitioners, 10(10), 763-768  DOI: https://doi.org/10.1016/j.nurpra.2014.08.0

HealthIT. (2019, January 9).  


Advancing care information reporting. https://www.healthit.gov/topic/federal-incentive-programs/MACRA/MIPS/advancing-care-information-reporting

HealthIT. (2019, February 12).  Meaningful Use and the Shift to the Merit-based Incentive Payment System.  https://www.healthit.gov/topic/meaningful-use-and-macra/meaningful-use

Liao, J. M., Shea, J. A., Weissman, A., & Navathe, A. S. (July, 2018). Physician Perspectives In Year 1 Of MACRA And Its Merit-Based Payment System: A National Survey. Health Affairs, 37(7). https://doi.org/10.1377/hlthaff.2017.1485


Chen, M., Guo, S., & Tan, X. (2019). Does Health Information Exchange Improve Patient Outcomes? Empirical Evidence From Florida Hospitals.  Health Affairs, 38(2), 197–204. doi: 10.1377/hlthaff.2018.05447 


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