Student Name
Capella University
NURS-FPX 6614 Structure and Process in Care Coordination
Prof. Name
Date
Defining a Gap in Practice: Executive Summary
This executive summary examines how Electronic Health Records (EHRs) can strengthen care coordination for adult patients living with chronic diseases. The central focus is identifying a current practice gap where fragmented communication and limited data sharing reduce the quality and continuity of care. By structuring the issue using the PICOT framework, this summary highlights how technology-driven solutions can improve interdisciplinary collaboration and patient outcomes. In particular, EHR integration is positioned as a key strategy for reducing inefficiencies and supporting evidence-based decision-making across care teams.
A major concern in current healthcare delivery is the lack of seamless coordination among providers, often resulting in delayed interventions and incomplete patient information exchange. These inefficiencies are especially problematic in chronic disease management, where long-term monitoring and consistent follow-up are essential. A centralized EHR system addresses this gap by offering a unified platform that consolidates patient records, improves accessibility, and enhances communication between multidisciplinary teams. This shift supports timely clinical decisions and reduces duplication of services.
NURS FPX 6614 Assessment 1 Defining a Gap in Practice
From a strategic standpoint, healthcare leaders are encouraged to consider phased implementation approaches such as pilot testing, stakeholder engagement, and structured training programs. These steps ensure smoother adoption of digital systems while minimizing operational disruption. Ultimately, success is measured through improved clinical outcomes, including reduced hospital readmissions, improved continuity of care, and better chronic disease control.
Analysis of Clinical Priorities and PICOT Application
Clinical Priorities in Chronic Disease Management
Managing adults with chronic conditions requires a comprehensive and sustained approach due to the complexity and long duration of these illnesses. Common conditions such as diabetes, hypertension, cardiovascular disease, and chronic respiratory disorders require continuous monitoring, medication adherence, and lifestyle modifications (Kompaniyets, 2021). Preventive care strategies—such as regular screenings, immunizations, and health education—are essential in reducing disease progression and complications.
Despite these clinical priorities, one of the most significant challenges is poor care coordination across healthcare settings. In many cases, patient data is fragmented across multiple systems, limiting real-time communication among providers. This lack of integration often leads to inconsistent treatment plans and avoidable clinical errors. Digital health tools, particularly EHR systems, telehealth platforms, and secure messaging systems, can significantly reduce these gaps by improving information flow and continuity of care (Lewinski et al., 2022).
PICOT Question Framework
A structured PICOT question helps define the clinical inquiry and guide evidence-based practice improvements.
| PICOT Element | Description |
|---|---|
| Population (P) | Adults diagnosed with chronic diseases in healthcare settings |
| Intervention (I) | Implementation of a centralized Electronic Health Record (EHR) system |
| Comparison (C) | Standard care without integrated digital coordination tools |
| Outcome (O) | Improved care coordination and communication among providers |
| Time (T) | Within a two-year implementation and evaluation period |
This PICOT framework demonstrates that centralized EHR adoption can significantly enhance coordination and communication in chronic disease care. Evidence indicates that EHR systems improve data sharing across providers, reduce duplication of services, and support safer, more efficient care delivery (Watterson et al., 2020; Manov et al., 2020).
Interventions, Resources, and Outcome Planning
Evaluation of Resources and Services
A variety of digital tools and services can be used to improve chronic disease management and care coordination. These resources enhance communication, patient engagement, and continuous monitoring of health conditions.
| Resource | Function | Benefit |
|---|---|---|
| EHR Systems | Centralized patient data storage | Improves interdisciplinary communication |
| Telehealth | Remote clinical consultations | Expands access to care services |
| Patient Portals | Patient access to health records | Encourages self-management |
| Mobile Applications | Symptom tracking and reminders | Improves adherence and engagement |
While these technologies offer significant benefits, barriers such as data security concerns, limited digital literacy, and unequal access to technology remain important challenges. Addressing these issues requires targeted training programs, robust cybersecurity measures, and organizational support systems (Fjellså et al., 2022; Lewinski et al., 2022).
Care Coordination Intervention: Clinical Pathways
A key intervention to improve chronic disease management is the use of standardized clinical pathways. These evidence-based protocols guide care delivery by ensuring consistency, reducing variation, and aligning practices with clinical guidelines (Bardhan et al., 2020). Clinical pathways typically involve interdisciplinary collaboration, where care teams jointly develop structured treatment plans based on patient needs.
When integrated into EHR systems, clinical pathways become more effective by enabling real-time documentation, monitoring, and communication. This integration ensures that all healthcare professionals involved in a patient’s care have access to up-to-date information, improving coordination and reducing delays in treatment adjustments.
Collaborative Strategy and Nursing Diagnosis
The identified nursing diagnosis is “ineffective self-health management” among adults with chronic illnesses. This condition is often linked to limited health literacy, insufficient support systems, and fragmented healthcare delivery. Addressing this issue requires a collaborative, patient-centered approach that integrates education, counseling, and continuous support (Orrego et al., 2021).
Technology plays an important role in strengthening collaboration. Shared EHR access allows providers to maintain consistent care plans, while mobile health applications enable patients to actively participate in managing their conditions. Nurses, in particular, play a central role in monitoring progress, providing education, and reinforcing adherence to treatment plans (Fjellså et al., 2022).
Planning for Implementation and Measuring Outcomes
Successful implementation of a coordinated care model requires engagement from all stakeholders, including clinicians, IT professionals, administrators, and patients. Collaboration with EHR vendors is essential to ensure system customization aligns with organizational needs and chronic care requirements.
Training programs must be provided to ensure staff competency in using digital tools effectively. Additionally, pilot testing allows organizations to identify workflow challenges before full-scale implementation. Standardized protocols should be developed collaboratively to ensure consistency in care delivery across departments.
Expected Outcomes of Implementation
| Outcome | Description |
|---|---|
| Improved Communication | Faster and more accurate information sharing among providers |
| Enhanced Efficiency | Reduced duplication of tests and services |
| Increased Patient Engagement | Patients actively participate in care decisions |
| Fewer Adverse Events | Better monitoring and medication safety |
| Improved Health Outcomes | Reduced hospital admissions and stabilized chronic conditions |
A key assumption in this model is that sustained stakeholder engagement and continuous quality improvement efforts will ensure long-term success. Regular performance evaluation and system optimization are essential for maintaining effectiveness (Watterson et al., 2020).
References
Bardhan, I., Chen, H., & Karahanna, E. (2020). Connecting systems, data, and people: A multidisciplinary research roadmap for chronic disease management. MIS Quarterly: Management Information Systems, 44(1), 185–200. https://doi.org/10.25300/MISQ/2020/14644
Fjellså, H. M. H., Husebø, A. M. L., & Storm, M. (2022). EHealth in care coordination for older adults living at home: Scoping review. Journal of Medical Internet Research, 24(10), e39584. https://doi.org/10.2196/39584
NURS FPX 6614 Assessment 1 Defining a Gap in Practice
Kompaniyets, L. (2021). Underlying medical conditions and severe illness among 540,667 adults hospitalized with COVID-19, March 2020–March 2021. Preventing Chronic Disease, 18. https://doi.org/10.5888/pcd18.210123
Lewinski, A. A., Walsh, C., Rushton, S., Soliman, D., Carlson, S. M., Luedke, M. W., Halpern, D. J., Crowley, M. J., Shaw, R. J., Sharpe, J. A., Alexopoulos, A.-S., Tabriz, A. A., Dietch, J. R., Uthappa, D. M., Hwang, S., Ball Ricks, K. A., Cantrell, S., Kosinski, A. S., Ear, B., & Gordon, A. M. (2022). Telehealth for the longitudinal management of chronic conditions: Systematic review. Journal of Medical Internet Research, 24(8), e37100. https://doi.org/10.2196/37100
NURS FPX 6614 Assessment 1 Defining a Gap in Practice
Manov, N. F., Srulovici, E., Yahalom, R., Perry-Mezre, H., Balicer, R., & Shadmi, E. (2020). Preventing hospital readmissions: Healthcare providers’ perspectives on “impactibility” beyond EHR 30-day readmission risk prediction. Journal of General Internal Medicine, 35(5), 1484–1489. https://doi.org/10.1007/s11606-020-05739-9
Orrego, C., Ballester, M., Heymans, M., Camus, E., Groene, O., Niño de Guzman, E., Pardo-Hernandez, H., & Sunol, R. (2021). Talking the same language on patient empowerment: Development and content validation of a taxonomy of self-management interventions for chronic conditions. Health Expectations. https://doi.org/10.1111/hex.13303
Watterson, J. L., Rodriguez, H. P., Aguilera, A., & Shortell, S. M. (2020). Ease of use of electronic health records and relational coordination among primary care team members. Health Care Management Review, 45(3), 1. https://doi.org/10.1097/hmr.0000000000000222