Clinical Information System: Clinical Documentation System
Clinical Documentation System
Excelsior College October 6, 2013
Clinical Documentation System
Clinical information system (CIS) collects patient data in real time, stores healthcare data and information using secure access to the healthcare team. (McGonigle & Garver Mastrian, 2012, p. 554). The CIS that is used at Texas Health Dallas is CareConnect. CareConnect is used by all of the Texas Health Resources (THR) encompassing 25 hospitals, affiliated physician offices, and ancillary facilities. CareConnect allows physicians and management to access the system on their mobile devices and home computer for real time data. The shift for CIS is set for implementation throughout the United States …show more content…
by 2015. The clients served are those in the community that THR provides healthcare services to. The electronic health record is shared amongst the healthcare team and other affiliates.
Data collection can be continuously updated, used for “statistical evaluation for purposes of quality improvement, outcome reporting, resource management, and public health surveillance.”(Yamada, 2008, p. 5). Data collection is generally initiated in the ER, and other times when the patient is at the physician 's office or in the outpatient service line. To reference inpatient services, data collection begins in the ER. The patient 's allergies, current medications, medical history, vital signs, immunizations, suicide screening and domestic violence screening are all obtained upon the patient 's arrival to the ER. The gathering of this information, initiates a process for interdisciplinary data collection. All healthcare team members can access a patient’s previous visits whether it is outpatient, inpatient, diagnostic or office visit. Labs and radiological tests are shown by date and time and are listed in chronological order. The clinical staff member logs into the system, selects their patient using a tab-based system, which allows for the clinician to retrieve the data they are searching for. For example, there are specific tabs set up for medications, patient history, results, and orders.
The CareConnect system functions as it is intended to as it allows the clinical staff to obtain the data entered, and promote a care plan based system which focuses on the diagnosis of the patient. CareConnect provides an organizational tool for the nurse to be able to update and enter data on an ongoing basis, as well as, making it possible for multiple users to access a specific patient’s chart simultaneously. All information is centralized which allows the healthcare team access and prevent redundant testing. This system allows for orders and patient specific data to be clearly written which avoids the concern of illegible handwriting risking potential error.
“Workflow analysis is a study of the way documents, information and people related to a process move through an organization, in order to improve efficiency.” (Wilkerson-George, Roark, Turner, Urby, & Kerr-Kanabec, 2011, p. 8). CareConnect supports workflow by the ease of use when charting patient data. For example: when a patient arrives in the emergency room, the patient is triaged using the triage tab. This prompts the nurse to enter all required documentation during this time as directed by “best practice” standards. Best practice standards are the required screening tabs such as fall scale, suicide screening and immunization screening. Next order sets for a given chief complaint are selected and the physician selects specific patient orders. Order sets can be defined as labs, diagnostic studies and nursing interventions for that particular complaint. For example: a patient presents with chest pain, the order set includes: Chest x-ray, EKG, CBC, CMP, Troponin, continuous heart monitoring and pulse oximetery. The next step involves assigning to a room and physician then signs up for the patient then reviews patient information via the navigator selection. The navigator will allow healthcare team to see what interventions that have been completed since the time of arrival which includes actual patient assessments, vital signs, general notes, and all procedural and laboratory data. All staff in the emergency room uses the ED navigator as it is updated on a real time basis.
One way THR has implemented safety for patients is through documentation tool called Safety Action Learning Tool (SALT).
Risk management, quality, performance improvement and patient safety use the SALT for data collection. The SALT is not part of the medical record but is part of data collection process. CareConnect has some safety implementation built into patient assessments; an example would include the fall risk scale. Patients are screened for a falls at the time of admission, during each shift, with any acute change in condition, and at discharge. If it is determined the patient is a high fall risk, the nurse is then prompted to implement fall risk interventions, which sets the stage for ongoing risk assessment. The process of completing an incidence report is recorded when a fall or near miss event occurs by the person reporting using the SALT tool. Other data collected under the SALT system would include number of acquired nosocomial infections while hospitalized. By having this assessment tool complies the entered data from which some of the information must reported, thus, affecting reimbursement …show more content…
rates.
The safety committee uses the data to improve the system and educate all health care workers on outcomes. The research team, consisting of physicians, nurses and other ancillary team members, measure data on certain patient-centered outcomes. For example, patients in the congested heart failure (CHF) program are measured for compliance of medication regime and 30-day hospital readmissions. Another use of data collection that is reported on the national level involves infectious diseases. Core measures track evidence-based standards of care that the Center for Medicare and Medicaid established and report to the public. Core measures that require data collection for admitted patients are acute myocardial infarction, pneumonia, CHF, and surgical care improvement. These are measured by the key actions that are evidence-based appropriate for that particular category. For example, if a patient has an acute myocardial infarction the core measure states the patient is supposed to be on aspirin, statin, beta-blocker, ACE inhibitors, non-smoking and compliant with a cardiac diet. If the patient is allergic to aspirin and displays low heart rate resulting from the beta-blocker, then the physician needs to document the rationale at the time of discharge as to why the patient was not sent home with those particular medications.
At THR there is a safety officer that is responsible for analyzing patient outcomes from data obtained by the Care Connect system. The safety officer is responsible for reporting the collected data to local and national authorities for safety and compliance. For instance, if the administration of a particular medication causes a fatal event, the safety officer and the compliance department both investigate the cause and report the findings. An example of a reportable incident would be administering a medication to a patient, which ended up with an anaphylactic reaction, and caused a patient death (sentential event). The development of a barcode scanning system is a patient safety measure that is utilized to reduce errors during medication administration, lab draw collection, and the administration blood products. This ensures a safety net for patients and healthcare workers that follow the guidelines incorporating the five patient identifiers. All patient rooms in the hospital are equipped with computers at the bedside that include a handheld scanning device, which contribute to a safer practice by supporting correct patient by arm band scanning identification. A new addition to CareConnect supports the ability of the system to record vital signs in real time. Values are automatically recorded in 1 minute and 5-minute increments for obtaining the most up to date vital signs. This will allow the nurse additional free time to focus on patient care instead of having to routinely manually enter vitals, which could result in a data entry error. This process will allow the healthcare team to access current vital signs for any given patient in a specific area that has been selected to view in the electronic health record. Areas that could be selected involve the emergency department, PACU, ICU, OR, and a critical care area.
Some of the strengths of the CareConnect system includes the verification the five identifiers prior to medication administration via armband barcode scanning and the ability of the system to require dual entry verification by two nurses prior to blood product and insulin administration. Prior to the administration of any medication, a pharmacist must acknowledge or correct the medication in the system before the nurse can access the medication. The system will generate pop up tab that prompts the nurse for unrecommended uses or dosages for medications. The nurse is also responsible for verifying orders placed by in the system by physician and report this to the oncoming staff as this is the proper SBAR handoff that THR has implemented.
A limitation to the CIS is the risk for potential for human error by incorrect patient selection.
One type of error in the ER is the possibility for a physician to place orders in the wrong patient’s chart. Physicians are often responsible for more than 20 patients at a time, as well as, supervising the physician assistant’s patients as well. Good care coordination between the nurse and the physician is a key component to assure orders are written on the correct patient and noting discrepancies as they arise. The nurse needs to thoroughly review orders ongoing for updates and question entries inputted by the MD. Even with systems ability to note discrepancies and providing pop up screens for healthcare workers, the potential for human error occurs when clinician has the ability to override warnings. The pop up warnings can be useful in prompting the healthcare worker to critically think, but can also cause harm to the patient if the clinician does not take the warning into account. Quality outcomes are measured by the reports that the safety and compliance auditors receive based upon reviewing data, thus, allowing the information to shared with staff in education sessions. “Meticulous testing of electronic healthcare record (EHR) products is critical to their safety.”(Hoffman & Podgurski, 2011, p. 79). In-services throughout the year to point out system updates are necessary for the CIS to be progressive and for the clinical staff to be made aware of changes. If a
particular hospital unit is not maintaining the standards of care using CareConnect system, then remediation will occur with ongoing classes to help with better implementation of data. Currently, barcode scanning rates are measured quarterly and presented to the staff in departmental meetings. If it determined that an individual staff member falls below 95%, they are brought into the manager’s office for a coaching session. In those cases where more than one occurrence is noted, the staff member will be signed up for a remedial class on barcode scanning.
“Evidence-based nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences.”(McGonigle & Garver Mastrian, 2012, p. 309). CareConnect has specialized care plans set up for specific clinical diagnoses which automatically establishes the care to be provided, projects potential diagnosis concerns, and sets into place interventions that are evidence based in order to have the best patient outcomes. By standardizing care plans by diagnosis, CareConnect has made the utilization of evidence-based practice easier for the nurse and devised a framework for the patient population referencing particular diagnosis. For example, a patient with the diagnosis of heart failure must meet certain criteria prior to discharge that is evidence based. Problems that would be identified are: medication compliance and understanding, restricted sodium diet, left ventricular function, weight monitoring daily, smoking cessation, and signs and symptoms of heart failure. The care plan is arranged by the nurse on admission, adjusted each shift to note condition changes, and review again at the time of discharge. Goals are monitored and measured by the research team as the data is automatically sent to the core measures group. On discharge, alerts are sent reminding the nurse and physician to include appropriate appointments and recommended services for patients based upon their specific diagnoses. Separate departments to collect data for ongoing evidence based practice measures monitor specific diagnoses such as CHF, COPD and diabetes. Infections control measures such as blood culture contamination rates are collected monthly and sent to each department. for review. Based on the findings, education from the lab is submitted if contamination rate exceed 3%, which is considered higher than normal. Evidence based practice for collecting blood cultures in all areas state: blood must not be obtained from the IV, chloraprep must be used to scrub the area in a circular motion for 30 seconds, and the area is dried thoroughly before obtaining the 10ml per bottle sample. A second sample is to be collected 15 minutes later following the same guidelines. Failure of clinician to adhere to the specific guidelines of blood culture collection can cause contamination rates to increase. Each clinician has a specific employee number attached to each culture collection to assist in determining data contamination rates and who may be held accountable.
Interdisciplinary collaboration across the healthcare system is an essential and critical component in providing the best care to the patient. Communication between the patient and the interdisciplinary team in making the system work as a shared process. By establishing patient preferences and values will steer the exchange of information and promote continuity of care. The healthcare team must collaborate together with the patient to determine specific needs and set goals to provide the best possible outcome. The patient should be involved in the education and decision making process to effectively diagnosis and treat their condition. In today’s era, healthcare is patient centered. A patient 's health information can be accessed from any location, even outside the hospital or in an MD office, making data sharing more readily available. The ability to submit, track, and receive information from referrals and other hospitals is possible using the CareConnect system. Physicians are able to order labs and diagnostic tests from anywhere, as well as, directly admit to the hospital from their office providing all the required patient history and plan of care data. Reducing variability and promoting interdisciplinary collaboration maintain continuity of care. With the ease of electronically prescribing of mediations, physicians will have more accurate records on what medications have been recently filled. Electronic prescribing reduces errors in legibility, reduces the possibility of duplicating medications ordered, and sets the stage for better adherence to drug therapies. The healthcare team will be able to access all medications the patient has been prescribed and view the last date ordered ensuring continuity of care. Physicians will be able to avoid duplicate order testing and be able to retrieve all past data pertaining to a patient 's chart. Physicians will be able to electronically transmit patient data to other clinicians using CareConnect producing accurate electronic exchange. With this process in place, patients can avoid the process of repeating information between departments, thus, not having to recall their list of medications, medical and surgical history, and previous testing when seeing clinicians in network with the CareConnect system.
CareConnect promotes patient centered and focused care by keeping patient records easily accessible to clinicians. By clinicians using the electronic healthcare record, they are more receptive to providing collaborative information and saving the patient time from redundancy. Patients are becoming more empowered and involved in their healthcare and how information is recorded via a secured portal. CareConnect has dramatically changed communication, collaborations and operation by delivering one patient, one record.
References
Hoffman, S., & Podgurski, A. (2011). Meaningful Use and Certification of Health Information Technology: What about Safety?. Journal of Law, Medicine & Ethics, 77-80. http://dx.doi.org/doi:10.1111/j.1748-720X.2011.00572.x
McGonigle, D., & Garver Mastrian, K. (2012). Nursing Informatics and the Foundation of Knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning. Retrieved from
Wilkerson-George, J., Roark, T., Turner, R., Urby, R., & Kerr-Kanabec, K. (2011, January 21). Tips On Workflow Analysis During an EHR Implementation [Webinar]. U.S. Department of Health and Human Services, 1-53. Retrieved from http://www.hrsa.gov/healthit/toolbox/webinars/pdfs/workflow.pdf
Yamada, Y. (2008, July 1). The electronic health record as a primary source of clinical phenotype for genetic epidemiological studies. Genomic Medicine, 21(1-2), 5. http://dx.doi.org/10.1007/s11568-008-9021-1
Excelsior College October 6, 2013
Clinical Documentation System
Clinical information system (CIS) collects patient data in real time, stores healthcare data and information using secure access to the healthcare team. (McGonigle & Garver Mastrian, 2012, p. 554). The CIS that is used at Texas Health Dallas is CareConnect. CareConnect is used by all of the Texas Health Resources (THR) encompassing 25 hospitals, affiliated physician offices, and ancillary facilities. CareConnect allows physicians and management to access the system on their mobile devices and home computer for real time data. The shift for CIS is set for implementation throughout the United States …show more content…
by 2015. The clients served are those in the community that THR provides healthcare services to. The electronic health record is shared amongst the healthcare team and other affiliates.
Data collection can be continuously updated, used for “statistical evaluation for purposes of quality improvement, outcome reporting, resource management, and public health surveillance.”(Yamada, 2008, p. 5). Data collection is generally initiated in the ER, and other times when the patient is at the physician 's office or in the outpatient service line. To reference inpatient services, data collection begins in the ER. The patient 's allergies, current medications, medical history, vital signs, immunizations, suicide screening and domestic violence screening are all obtained upon the patient 's arrival to the ER. The gathering of this information, initiates a process for interdisciplinary data collection. All healthcare team members can access a patient’s previous visits whether it is outpatient, inpatient, diagnostic or office visit. Labs and radiological tests are shown by date and time and are listed in chronological order. The clinical staff member logs into the system, selects their patient using a tab-based system, which allows for the clinician to retrieve the data they are searching for. For example, there are specific tabs set up for medications, patient history, results, and orders.
The CareConnect system functions as it is intended to as it allows the clinical staff to obtain the data entered, and promote a care plan based system which focuses on the diagnosis of the patient. CareConnect provides an organizational tool for the nurse to be able to update and enter data on an ongoing basis, as well as, making it possible for multiple users to access a specific patient’s chart simultaneously. All information is centralized which allows the healthcare team access and prevent redundant testing. This system allows for orders and patient specific data to be clearly written which avoids the concern of illegible handwriting risking potential error.
“Workflow analysis is a study of the way documents, information and people related to a process move through an organization, in order to improve efficiency.” (Wilkerson-George, Roark, Turner, Urby, & Kerr-Kanabec, 2011, p. 8). CareConnect supports workflow by the ease of use when charting patient data. For example: when a patient arrives in the emergency room, the patient is triaged using the triage tab. This prompts the nurse to enter all required documentation during this time as directed by “best practice” standards. Best practice standards are the required screening tabs such as fall scale, suicide screening and immunization screening. Next order sets for a given chief complaint are selected and the physician selects specific patient orders. Order sets can be defined as labs, diagnostic studies and nursing interventions for that particular complaint. For example: a patient presents with chest pain, the order set includes: Chest x-ray, EKG, CBC, CMP, Troponin, continuous heart monitoring and pulse oximetery. The next step involves assigning to a room and physician then signs up for the patient then reviews patient information via the navigator selection. The navigator will allow healthcare team to see what interventions that have been completed since the time of arrival which includes actual patient assessments, vital signs, general notes, and all procedural and laboratory data. All staff in the emergency room uses the ED navigator as it is updated on a real time basis.
One way THR has implemented safety for patients is through documentation tool called Safety Action Learning Tool (SALT).
Risk management, quality, performance improvement and patient safety use the SALT for data collection. The SALT is not part of the medical record but is part of data collection process. CareConnect has some safety implementation built into patient assessments; an example would include the fall risk scale. Patients are screened for a falls at the time of admission, during each shift, with any acute change in condition, and at discharge. If it is determined the patient is a high fall risk, the nurse is then prompted to implement fall risk interventions, which sets the stage for ongoing risk assessment. The process of completing an incidence report is recorded when a fall or near miss event occurs by the person reporting using the SALT tool. Other data collected under the SALT system would include number of acquired nosocomial infections while hospitalized. By having this assessment tool complies the entered data from which some of the information must reported, thus, affecting reimbursement …show more content…
rates.
The safety committee uses the data to improve the system and educate all health care workers on outcomes. The research team, consisting of physicians, nurses and other ancillary team members, measure data on certain patient-centered outcomes. For example, patients in the congested heart failure (CHF) program are measured for compliance of medication regime and 30-day hospital readmissions. Another use of data collection that is reported on the national level involves infectious diseases. Core measures track evidence-based standards of care that the Center for Medicare and Medicaid established and report to the public. Core measures that require data collection for admitted patients are acute myocardial infarction, pneumonia, CHF, and surgical care improvement. These are measured by the key actions that are evidence-based appropriate for that particular category. For example, if a patient has an acute myocardial infarction the core measure states the patient is supposed to be on aspirin, statin, beta-blocker, ACE inhibitors, non-smoking and compliant with a cardiac diet. If the patient is allergic to aspirin and displays low heart rate resulting from the beta-blocker, then the physician needs to document the rationale at the time of discharge as to why the patient was not sent home with those particular medications.
At THR there is a safety officer that is responsible for analyzing patient outcomes from data obtained by the Care Connect system. The safety officer is responsible for reporting the collected data to local and national authorities for safety and compliance. For instance, if the administration of a particular medication causes a fatal event, the safety officer and the compliance department both investigate the cause and report the findings. An example of a reportable incident would be administering a medication to a patient, which ended up with an anaphylactic reaction, and caused a patient death (sentential event). The development of a barcode scanning system is a patient safety measure that is utilized to reduce errors during medication administration, lab draw collection, and the administration blood products. This ensures a safety net for patients and healthcare workers that follow the guidelines incorporating the five patient identifiers. All patient rooms in the hospital are equipped with computers at the bedside that include a handheld scanning device, which contribute to a safer practice by supporting correct patient by arm band scanning identification. A new addition to CareConnect supports the ability of the system to record vital signs in real time. Values are automatically recorded in 1 minute and 5-minute increments for obtaining the most up to date vital signs. This will allow the nurse additional free time to focus on patient care instead of having to routinely manually enter vitals, which could result in a data entry error. This process will allow the healthcare team to access current vital signs for any given patient in a specific area that has been selected to view in the electronic health record. Areas that could be selected involve the emergency department, PACU, ICU, OR, and a critical care area.
Some of the strengths of the CareConnect system includes the verification the five identifiers prior to medication administration via armband barcode scanning and the ability of the system to require dual entry verification by two nurses prior to blood product and insulin administration. Prior to the administration of any medication, a pharmacist must acknowledge or correct the medication in the system before the nurse can access the medication. The system will generate pop up tab that prompts the nurse for unrecommended uses or dosages for medications. The nurse is also responsible for verifying orders placed by in the system by physician and report this to the oncoming staff as this is the proper SBAR handoff that THR has implemented.
A limitation to the CIS is the risk for potential for human error by incorrect patient selection.
One type of error in the ER is the possibility for a physician to place orders in the wrong patient’s chart. Physicians are often responsible for more than 20 patients at a time, as well as, supervising the physician assistant’s patients as well. Good care coordination between the nurse and the physician is a key component to assure orders are written on the correct patient and noting discrepancies as they arise. The nurse needs to thoroughly review orders ongoing for updates and question entries inputted by the MD. Even with systems ability to note discrepancies and providing pop up screens for healthcare workers, the potential for human error occurs when clinician has the ability to override warnings. The pop up warnings can be useful in prompting the healthcare worker to critically think, but can also cause harm to the patient if the clinician does not take the warning into account. Quality outcomes are measured by the reports that the safety and compliance auditors receive based upon reviewing data, thus, allowing the information to shared with staff in education sessions. “Meticulous testing of electronic healthcare record (EHR) products is critical to their safety.”(Hoffman & Podgurski, 2011, p. 79). In-services throughout the year to point out system updates are necessary for the CIS to be progressive and for the clinical staff to be made aware of changes. If a
particular hospital unit is not maintaining the standards of care using CareConnect system, then remediation will occur with ongoing classes to help with better implementation of data. Currently, barcode scanning rates are measured quarterly and presented to the staff in departmental meetings. If it determined that an individual staff member falls below 95%, they are brought into the manager’s office for a coaching session. In those cases where more than one occurrence is noted, the staff member will be signed up for a remedial class on barcode scanning.
“Evidence-based nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences.”(McGonigle & Garver Mastrian, 2012, p. 309). CareConnect has specialized care plans set up for specific clinical diagnoses which automatically establishes the care to be provided, projects potential diagnosis concerns, and sets into place interventions that are evidence based in order to have the best patient outcomes. By standardizing care plans by diagnosis, CareConnect has made the utilization of evidence-based practice easier for the nurse and devised a framework for the patient population referencing particular diagnosis. For example, a patient with the diagnosis of heart failure must meet certain criteria prior to discharge that is evidence based. Problems that would be identified are: medication compliance and understanding, restricted sodium diet, left ventricular function, weight monitoring daily, smoking cessation, and signs and symptoms of heart failure. The care plan is arranged by the nurse on admission, adjusted each shift to note condition changes, and review again at the time of discharge. Goals are monitored and measured by the research team as the data is automatically sent to the core measures group. On discharge, alerts are sent reminding the nurse and physician to include appropriate appointments and recommended services for patients based upon their specific diagnoses. Separate departments to collect data for ongoing evidence based practice measures monitor specific diagnoses such as CHF, COPD and diabetes. Infections control measures such as blood culture contamination rates are collected monthly and sent to each department. for review. Based on the findings, education from the lab is submitted if contamination rate exceed 3%, which is considered higher than normal. Evidence based practice for collecting blood cultures in all areas state: blood must not be obtained from the IV, chloraprep must be used to scrub the area in a circular motion for 30 seconds, and the area is dried thoroughly before obtaining the 10ml per bottle sample. A second sample is to be collected 15 minutes later following the same guidelines. Failure of clinician to adhere to the specific guidelines of blood culture collection can cause contamination rates to increase. Each clinician has a specific employee number attached to each culture collection to assist in determining data contamination rates and who may be held accountable.
Interdisciplinary collaboration across the healthcare system is an essential and critical component in providing the best care to the patient. Communication between the patient and the interdisciplinary team in making the system work as a shared process. By establishing patient preferences and values will steer the exchange of information and promote continuity of care. The healthcare team must collaborate together with the patient to determine specific needs and set goals to provide the best possible outcome. The patient should be involved in the education and decision making process to effectively diagnosis and treat their condition. In today’s era, healthcare is patient centered. A patient 's health information can be accessed from any location, even outside the hospital or in an MD office, making data sharing more readily available. The ability to submit, track, and receive information from referrals and other hospitals is possible using the CareConnect system. Physicians are able to order labs and diagnostic tests from anywhere, as well as, directly admit to the hospital from their office providing all the required patient history and plan of care data. Reducing variability and promoting interdisciplinary collaboration maintain continuity of care. With the ease of electronically prescribing of mediations, physicians will have more accurate records on what medications have been recently filled. Electronic prescribing reduces errors in legibility, reduces the possibility of duplicating medications ordered, and sets the stage for better adherence to drug therapies. The healthcare team will be able to access all medications the patient has been prescribed and view the last date ordered ensuring continuity of care. Physicians will be able to avoid duplicate order testing and be able to retrieve all past data pertaining to a patient 's chart. Physicians will be able to electronically transmit patient data to other clinicians using CareConnect producing accurate electronic exchange. With this process in place, patients can avoid the process of repeating information between departments, thus, not having to recall their list of medications, medical and surgical history, and previous testing when seeing clinicians in network with the CareConnect system.
CareConnect promotes patient centered and focused care by keeping patient records easily accessible to clinicians. By clinicians using the electronic healthcare record, they are more receptive to providing collaborative information and saving the patient time from redundancy. Patients are becoming more empowered and involved in their healthcare and how information is recorded via a secured portal. CareConnect has dramatically changed communication, collaborations and operation by delivering one patient, one record.
References
Hoffman, S., & Podgurski, A. (2011). Meaningful Use and Certification of Health Information Technology: What about Safety?. Journal of Law, Medicine & Ethics, 77-80. http://dx.doi.org/doi:10.1111/j.1748-720X.2011.00572.x
McGonigle, D., & Garver Mastrian, K. (2012). Nursing Informatics and the Foundation of Knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning. Retrieved from
Wilkerson-George, J., Roark, T., Turner, R., Urby, R., & Kerr-Kanabec, K. (2011, January 21). Tips On Workflow Analysis During an EHR Implementation [Webinar]. U.S. Department of Health and Human Services, 1-53. Retrieved from http://www.hrsa.gov/healthit/toolbox/webinars/pdfs/workflow.pdf
Yamada, Y. (2008, July 1). The electronic health record as a primary source of clinical phenotype for genetic epidemiological studies. Genomic Medicine, 21(1-2), 5. http://dx.doi.org/10.1007/s11568-008-9021-1