Assessment 3: Reflection on EHR Accuracy, Data Mining, and Clinical Decision Making

Complete three EHR Go activities relating to medication reports, order verification, and risks and clinical warnings. Write a reflection paper (1-page) addressing key lessons learned relating to EHR accuracy and standards, data mining, and legal and ethical considerations surrounding EHR-CDS usage.

Data mining is the process of discovering and extracting patterns within a set of data. Its main goal is to transform data into meaningful information, typically for decision-making purposes. Identifying patterns within data helps to depict the data and to predict future behaviors or patterns. Information such as this helps to improve quality of care, reduce costs, and support organizational services, such as disease management and resource utilization. Historically, conducting this kind of research was extremely labor intensive. With the advent of electronic health record systems and clinical decision support (CDS) systems, health care professionals now have access to large volumes of highly standardized and electronically stored data.

One type of CDS system involves itemizing a set of symptoms and circumstances and then searching the potential range of diagnoses as the source of those symptoms. A set of internal organizational guidelines govern the use of these activities within the CDS system. The high-level concept is to build an application capable of integrating the information and then identifying a potential diagnosis in the same way a human expert would make a diagnosis. 

A wide range of potential ethical and legal issues relate to the creation, implementation, and use of CDS systems. Clinical decision support assists with analyzing and interpreting health data and then offering recommendations based on that data. An example of a legal and ethical issue related to the proper use of these systems involves practitioners’ ethical responsibilities. Do practitioners fully understand the implications of following the software recommendations when treating a patient?

The three EHR Go activities that form the bulk of this assessment show that data analysts need to be knowledgeable about a large amount of material. At the same time, it’s not sufficient to have a grasp of this information in isolation. Professional data analysts need to be able to integrate this information into a meaningful whole. They need to be able to see the big picture. How do the pieces of information relate to each other? As an example, incorrect data in the health record affects data mining activities. This, in turn, affects statistical results, which may result in a bad clinical decision. Alerts, warnings, and recommendations exist to help improve documentation but care also needs to be taken to ensure data security. 

In this third course assessment, you will complete EHR Go activities related to EHR accuracy and standards, data mining activities used to extract useful information for improving patient care, and the legal and ethical considerations surrounding EHR and CDS usage. In the second part of this assessment, you will integrate the key takeaways you’ve learned from completing the activities into a meaningful whole by writing a brief reflection paper. 

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

Your third assessment consists of two parts:

Part 1: Complete these three EHR Go activities

These three activities form the bulk of this assessment:  

• For this first activity, you will use EHR-CDS functions to create a medication report based on patient chart information. You will then use the created report to make recommendations about how to improve EHR-CDS functions for more effective clinical decision making.
  • EHR Go: Medication Report.
  • Enter your answers for this activity directly into a Word document. Also, copy and paste the medication report into the same Word document. 
• In the second activity, you will use clinical decision support functions, such as CPOE, to enter physician medication orders.  
  • EHR Go: Verifying Orders.
  • Add your answers for this activity directly into the Word document you’ve created for your EHR Go activities. 
• In the third EHR Go activity, you will analyze a physician’s actions, document an EHR, and recommend physician performance requirements for using EHR clinical decision functions. The recommendations and standards will focus on physician order entry, medication warnings, and alerts.
  • EHR Go: Risks and Clinical Warnings
  • Add your answers for this activity directly into the Word document you’ve created for your EHR Go activities. 

You will create one document that contains your answers to each of the three activities. Remember to copy and paste the medication report you created for the first activity into your document.

Part 2: Write a one-page reflection paper on the topics covered in the EHR Go activities

Be sure to address these three questions in your reflection paper:

• What is the relationship between the three EHR Go activities you completed?  In other words, how do the concepts you learned relate to each other?
• What were your two or three most important takeaways about the concepts of EHR accuracy and standards, data mining, and legal and ethical considerations?
• What is a remaining question you have about these concepts?

Reminders:

• Your takeaways may be new information that you didn’t know before or they may confirm what you already knew.
• Be sure to include supporting examples in your reflection paper along with references to current, scholarly, and/or authoritative sources.

Additional Requirements

• Length: 1-page, double-spaced reflection paper.
• EHR Go activities: Submit your completed EHR Go activities in a Word document. Remember to copy and paste your medication report into this document. 
• Font: Times Roman, 12 point font.
• Writing: Create clear, well organized, professional documents that are 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 APA refresher: APA Style and Format.
• Resources: Data Mining
  • Karami, M. (2015). Clinical decision support systems and medical imaging. Radiology Management, 37(2), 25–32.
  • Yang, J., Kang, U., & Lee, Y. (2016). Clinical decision support system in medical knowledge literature review. Information Technology and Management, 17(1), 5–14.
  • Resources: Standards
    • Marchant, G. E., Scheckel, K., & Campos-Outcalt, D. (2016). Contrasting medical and legal standards of evidence: A precision medicine case study. Journal of Law, Medicine & Ethics, 44(1), 194–204.
    • Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe, 12(4), 369–373. Retrieved from https://doaj.org/article/9fa570cd9cf64198bd3be8304…
    • Metzger, N. L., Chesson, M. M., & Momary, K. M. (2015). Simulated order verification and medication reconciliation during an introductory pharmacy practice experience. American Journal of Pharmaceutical Education, 79(7), 1.
    • Resources: Legal and Ethical Considerations
      • Brown, E. (2015, April 20). Digital health data at risk, report warns. Los Angeles Times, A9.
      • Cajanding, R. J. M. (2017). Administering and monitoring high-alert medications in acute care. Nursing Standard, 31(47), 42.
      • Privacy Rights Clearinghouse. (2018). Health privacy: HIPAA basics – A brief history of HIPAA. Retrieved from https://www.privacyrights.org/content/health-priva… history