CLC Business Plan- Electronic Medical Record (EMR) Implementation

CLC Business Plan- EMR Implementation
I. Introduction
a. Vision
Enhancing our organization while providing a safer and higher quality of care to patients.
b. Mission Statement
To provide a more seamless flow of information within the organization and approved health care facilities within the industry.
c. Background
The senior executives of the hospital asked the Information Technology (IT) project manager to come up with a proposal for the 200-bed organization that would implement the trending Electronic Medical Record (EMR). “Nearly one in four (23.9 percent) of physicians reported using full or partial electronic medical records (EMRs) in their office-based practice in 2005 – a 31 percent increase from the 18.2 percent reported in 2001″ (More Physicians, 2006). After deep research, the senior executives found the EMR to be an advantageous possibility for the organization. They asked the IT project manager to propose a business plan that would cover the hospital, the four clinics within the local community, and the 30-member primary care physicians’ group.
d. Goals
? To better track patient data.
? To make faster decisions on patient health.
? To quickly transfer patient information.
? To identify patients due for screenings and preventative care visits.
? To better protect patient data and information.
? To measure and monitor certain parameters on patients; for example new medication or vital signs.
e. Objectives
? To improve the overall quality of care within the organization and health care industry.
? To enhance patient privacy.
? To improve treatment and diagnosis.
? To improve efficiency throughout the organization and provide care faster.
? To enhance security on patient data and information.
? To increase productivity and the number of patients seen within a day.
II. Description of product/service
a. What is EMR?
Davidson, in 2009, explained an EMR as:
The over-reaching concept of taking all medical information, including hand-written doctor’s notes, medical records, x-rays, test results, surgical video, audio, prescriptions and any other patient information and storing it in an application that organizes it and makes it instantly available to medical providers. This data would be stored by the government and, subject to the approval of the patient, made accessible to healthcare providers.
b. Vendor & Description
Epic Electronic Medical Record (EMR)
? Private and employee-owned; found in 1979 (Epic, 2015).
? Award-winning!
? One of the best EMR systems in the health care industry!
? The “software is quick to implement, easy to use and highly interoperable through industry standards” (Epic, 2015).
? User-friendly
? Improves care with its “one patient, one record” approach (Epic, 2015).
? Patients are able to access their chart and event make appointments.
? High in service and support
c. Benefits/Advantages of EMR Software
? Reduced costs; “the estimated net benefit from using an electronic medical records (EMR) [system] for a 5-year period was $86,400 per provider” (Arevalo, 2005).
? Improved Care
? Stronger communication between patient and the clinicians.
? Increased Productivity
? Reduced Error
? Increased Accuracy
? Increased Privacy and Security
d. Integration of Current Electronic Data Sources
? Ordering; orders transmitted through EMR system to laboratories, pharmacies, and results on standby.
? Reporting & Analysis; results and feedback can be reported while work performance can be measured.
? Messaging; provides more completed documentation, availability, accuracy, and timeliness.
? Billing; though the EMR system is financially rewarding to the organization because claims could be processed faster due to having supported documentation all together in one location.
III. Business and Industry Profile
a. Health Care Industry Profile
The healthcare market is one of the fastest growing business markets in the world. The United States of America makes up more than 42% of the value of the healthcare sector. In 2011 the healthcare provider sector had a growth of 5.7% taking it to an estimated value of $2,684 billon. Outpatient care accounts for 50% of the market with inpatient care following at 19%. The market is expected to continue to grow by at least 5% each year. The estimates value forecast for 2016 is $3,455 billion (Healthcare Providers, 2012).
b. Business Profile
Hospital X is a 200 bed hospital that serves the inner-city community. The hospital also has a 30 member primary care physician group in the hospital based clinic as well as four clinics throughout the community. Over the past three years the hospital has seen a growth of 4.5% and is expected to continue on the trend of growth over the next four projected years.
IV. Marketing Components
For the marketing aspect of implementing an Epic, the Electronic Medical Records system, there are many bases that need to be covered in order for an EMR to be marketed to its greatest ability. First, it is important to market the EMR system internally so that the employees and current patients of Hospital X understand what the system is. The EMR system Epic contains a number of benefits for employees of the hospital, as well as the patients that already are customers of the facility. The Epic system has an acute care section of the EMR for treating patients who need immediate attention. Furthermore, Epic has an Ambulatory, Laboratory, and Surgery section of the EMR for those specific departments of the hospital (Epic, 2015). In addition to these aspects of the system, Epic is used as one database, so other databases do not need to be purchased in order for the system to work; Epic is all-inclusive. Epic is one of the best systems to implement because it is an easy and quick process and is also and simple system to use and get adjusted to (Epic, 2015). As far as educating the employees on how to use Epic, Epic has an e-learning system that allows employees to start learning how to use the system, which makes the learning and training process much quicker than the typical EMR system (Epic, 2015).
a. Internal Marketing
In order for the employees to be able to learn about the benefits that come with implementing Epic into their facility, the operations managers of the hospital will hold a mandatory meeting for all employees to attend. At this meeting the operations managers will inform the employees about implementing the system Epic and will provide the advantages that will come with this implementation. Next, a newsletter will be sent out to employee’s emails stating the date of implementation, along with the advantages of the system, and a date for when their training will begin (Irene, 2009). Making sure that enough information is provided to the employees is crucial when implementing a new system because many employees are hesitant to change, so making sure that the employees are aware and educated is very important.
b. Patient Marketing
For patients, Epic contains a patient portal part of the system where patients can log on to the website and view their own medical records and information. In addition, patients can enter a billing area of the Epic system and view past and current balances, as well as make payments (Epic, 2015). To market to the current patients of Hospital X, sending out postcards to the current patients to let them know about the new technology at Hospital X and how they can benefit from them (Irene, 2009). Making sure that all people can understand the vocabulary used is very important because EMRs can be difficult to understand, so using common words to describe the EMR system is essential to appeal to the patients.
c. External Marketing
In order to capture the attention of the external public and market to those who are not current patients of Hospital X, the main advantages of Epic must be visible to all people. Post a billboard in a high traffic area of town with the words Epic and Patient Portal access and most importantly Hospital X should all be highlighted on the billboard (Bizzle, 2015). It is essential that the name of the hospital is clear so that the public does not confuse the promotion for another hospital in the same area. Making sure that the patient portal aspect of Epic is highlighted is also crucial because patient portals are very appealing to many of those who like to have access to their medical records. The billboard must depict something that is appealing to the public that will make them want to learn more about what Epic and Hospital X can do for them, whether it be pictures on the billboard or the typography of the word on the billboard (Bizzle, 2015). Yard signs can also be an effective way to market the EMR system. Posting yard signs that state that a patient portal is available in front of Hospital X can draw the attention of those passing by the hospital. Furthermore, radio commercials and television commercials are some of the best ways to market to the public, especially to those who do not current seek medical attention at Hospital X (Bizzle, 2015). Radio and television commercials will market the best because it is audio marketing, so individuals will be hearing the advantages and benefits of Hospital X’s newest technology.
d. Marketing Aspects
Marketing the aspects of Epic that are unique than other EMR systems is very important because it allows for Epic to stand out and offer something different to the patients. Being aware of the offers that the other health care facilities provide within the area is important for marketing so that Epic can be marketed in a different way than what the other facilities are using. It will also be helpful to market Epic when taking into consideration the demographics of the area that Hospital X is in. Marketing the correct amount can help the facility save money so that they are not over doing it and spending a large amount of money when it is not necessary. Covering all angles, including the internal and external customers of the facility, as well as the employees and opposing facilities, will allow Hospital X to market Epic in a way that reaches all individuals in in the area.
V. Financial information
a. Current Financial Statement
Balance Sheet
Assets
Current Assets $160,000
Property & Equipment $545,000
Other Assets $275,000
Total Assets $980,000
Liabilities
Current Liabilities $97,000
Long-term Liabilities $530,000
Total Liabilities $627,000

Statement of Operations
Revenue
Patient Services Revenue $600,000
Other Revenue $12,000
Total Revenue $612,000
Expenses
Salaries & Benefits $325,000
Supplies $105,000
Insurance $21,000
Other $146,000
Total Expenses $597,000

Cash Flow Projection
Operating Activities $35,000
Investing Activities ($27,000)
Financing Activities ($1,200)
Net Cash/Cash Equivalents $6,800
Cash/Cash Equivalents at the Beginning of the Year $72,000
Cash/Cash Equivalents at the End of the Year $78,800

b. Cost of purchase of the system
The cost of software will depend on what type of system we have selected. For our Hospital X, we would choose Server Based EMR, which has a server locally present in our facility and the data would be backed up periodically (Mds medical, 2015). For such system the cost of purchase will include purchase of server system. It will also include cost of implementation and hardware cost. The hardware will include desktops, laptops, printer and scanner and others (Health IT, 2014). The breakdown of cost of purchase is:
• Software Purchase $15 million
• Server Purchase $5 million
• Hardware Purchase $5 million
• Implementation $10 million
c. Maintenance Cost
After implanting the software and other system, it will require periodic maintenance, to ensure everything is working smoothly. This will include software maintenance, hardware maintenance, server maintenance, and ongoing support. The breakdown of the cost of maintenance is:
• Software Maintenance $5 million
• Hardware Maintenance $3 million
• Server Maintenance $2 million
• Ongoing Support $3 million
d. Cost of training/staff education
Training is an important aspect of implementation of EMR in the hospital. All the nurses, office staff and physician needs to be trained with the new system. This will include cost of training nurses and other office staff, and training physician. The breakdown of cost of training is:
• Training Nurses and office staff $2 million
• Training Physician $1 million
e. Return on Investment
In order to properly plan for the financial impact of purchasing and implementing an electronic medical record, a cost-benefit analysis is necessary. This analysis at other hospitals have shown that the benefits of an EMR “far outweigh the cost of implementing and maintaining” it (Schmitt & Wofford, 2002). Thompson and Fleming (2008) report that the benefits electronic medical records offer to hospitals surpass the financial burden they cause them. Studies have found that these systems can “save an average of… $2.2 million annually for a typical 300-bed hospital” (p. 78). These same studies showed that nursing documentation time decreased by nearly 24 percent with the use of electronic documentation systems.
i. Meaningful use
EPIC makes software for mid-size and large medical groups, hospitals, and integrated healthcare organizations-working with customers that include community hospitals, academic facilities, children’s organization, safety net providers and multi-hospitals systems. EPIC’s integrated software spans clinical access and revenue functions and extends into the home. EPIC’s on track record is one of the best in healthcare. Its software is easy to implement, easy to use and highly interoperable through industry standards (EPIC, n.d.).
The HITECH portion of the ARRA stimulus package allocates funding for per hospital and per physician incentives and those who demonstrate “Meaningful Use” of EMRs. Epic fully endorses and formally adopts the Electronic Health Record (EHR) Developer Code of Conduct that encourages cooperative and transparent business practices among industry stakeholders. Epic has had a long history of embracing the Code’s key values and practices including: responsible development, patient safety, interoperability and data portability, clinical and billing accuracy, privacy and security and patient engagement. Epic EHRs earned certification in hospital and provider domains for ONC 2014 criteria. 6.3 million Patient records were exchanged securely on the Care Everywhere network in October 2014 – to and from Epic EHRs, non-Epic EHRs, HIEs, and government agencies.
In addition to the purchasing and maintenance cost of an EMR, financial incentive programs offered through the Centers for Medicare and Medicaid Services have to be considered. Some hospitals are eligible to receive $2 million or more in Medicare incentive payments (HealthIT.gov, 2013). The hospitals eligibility for the exact amount of money available for incentive payments should be determined and included in the proposed budget. These payments are earned by achieving various stages of meaningful use. Medicaid will make incentive payments for six years, with the first payment being $21,250 and the remaining years being $8,500. This set amount will be earned if the hospital meets the edibility requirements outlined by Medicaid.
ii. Increased patient safety/decreased sentinel events
In addition to these two cost savings offered with electronic medical records, there are unknown financial benefits provided as well. EMRs have been shown to reduce adverse events in hospitals. The financial impact of these events can only be compared with pre and post implementation data, but true cost savings cannot be compared because it is “impossible to measure an event that didn’t happen” (Thompson & Fleming, 2008, p. 79). Another way EMRs can improve finances at our hospital is through reduced use of other resources and decreased length of stays. It is estimated that hospitals implementing EMRs can expect a 5 to 10 percent reduction in the length of stay for patients. Uslu and Strausberg (2008) report that EMRs can help to improve “procedures … treatment quality … and quality control” (p. 680). It is important for Hospital X to consider these cost savings when budgeting for purchase costs of the system.

VI. Operational Plan
Many healthcare facilities and medical practices are already overwhelmed to discover that their administrative disbursements have skyrocketed. It is very common to find smaller healthcare facilities and medical practices struggle to be in pace with the astronomical demands of CMS, the federal government, referral management, scheduling and massive paperwork.
It is even a challenge for healthcare facilities and medical offices to recruit train and retain qualified and experienced staff. Selecting and implementing an EMR system can place and additional strain and burden on staff and resourced. If plans aren’t in place for this business decision, it will more likely create more work and defeat the intended purpose of increasing efficiency and productivity.
a. Needs Assessment
Hospital X will complete the needs assessment as a first step in EMR selection and implementation process. The primary purpose of this specific step is to clearly define what the hospital and clinics need in an EMR. Through this process Hospital X will discover needs that could be met without the aid of an EMR and promotes business systems or utilization of forms or improving current technology and information systems.
During Hospital X’s needs assessment, all stakeholders will be involved since ultimately they will be users of the proposed EMR. As a facilitative process, it will gain feedback from everyone. It will make everyone feel they have a stake of ownership and involvement in the proposed process, which will ultimately improve staff, nurses; and physicians buy in and use the EMR system later on.
Stakeholders fall under three categories:
1. Interface Stakeholders- those who function both internally and externally to the organization- that is, those who are on the interface between the organization and its environment. They are the medical staff, the hospital board of trustees, the corporate officer, stockholders, taxpayers or other contributors.
2. Internal Stakeholders – are those who operate entirely within the bounds of the organization and it includes management, professional and non-professional staff.
3. External Stakeholders- this group falls under three categories; some provide inputs into the organization, some compete with it and others have special interests in how the organization functions. These are the suppliers, patients, third party payers and the financial community (Fottler et.al. 1989).
The needs assessment will be performed in a straight forward way, all participants/stakeholders will be asked to give a description on their own perception as to how they think and surmise an EMR system will improve their jobs and what they think they needed in an EMR system. Some stakeholders who are not familiar with an EMR system will be further educated through a web based demonstration of one system (EPIC) to have an overview.
b. Readiness Assessment
This is an important step that Hospital X will have to undertake in order to unearth deficiencies that would warrant either delaying or discontinuing a search for an EMR until these deficiencies are resolved. Both the internal and external environment of Hospital X will be perused.
The following questions will be asked and ascertained:
1. What is the financial status of Hospital X? – Cash flow problems will make an EMR decision buy in compound to more financial strain. Considerations will be placed on financial challenges and affordability of the EMR.
2. What are the strategic plans of Hospital X? – If acquiring and EMR implementation is not part of strategic planning then there should be a need to reconsider EMR acquisition. Considerations were placed on healthcare merger/ acquisitions or affiliations.
3. Other technology implementation- Buying other technology as diagnostic devices or equipment may require significant resources for a given time period. It is unwise to place competing demands on limited resources by concurrently implementing EMR
4. Staffing changes- Change in staffing can put a strain on a healthcare facility and EMR implementation might end up creating a competition for resources. Training staff to use and EMR and they are preparing to leave causes problems. The stress of losing and replacing a nurse, physician, departmental manager or key finance/billing person makes concurrent implementation of an EHR not practical. Consideration were placed on assessment of staff leaving, roles in the healthcare facility, is there succession in place?
5. Is Hospital X understaffed? – introducing a new EMR will compound the problems and implementation failure will be the end result. Considerations will be placed on identifying units and departments understaffed and the need to hire new staff.
6. Will Hospital X be able to protect server location physically from unauthorized access? Considerations – space, power, cabling for computers, ergonomic furniture, and fire suppression power backup, and adequate air conditioning.
7. Are existing charts in Hospital X ready for conversion- it has to be kept in mind that it is a violation of the Confidentiality of Medical information Act to negligently dispose of, abandon or destroy medical records in a manner that fails to preserve confidentiality (Civil Code56.101)?
8. Has Hospital X assigned Champions –physicians, pharmacists, radiology and nurses and staff-it is essential for people to lead or support an EMR. Considerations will be placed on champions in very unit or department and if there will be an anticipated resistance?
9. Does Hospital X have high speed connectivity? This is very important for data exchange
10. Does Hospital X need external consulting needs in EMR implementation? Consideration was placed on costliness.

c. Workflow Analysis
A workflow analysis involves reviewing how a healthcare facility completes a work task associated with the patient encounter and all related components. Some examples are:
• Hospital rounds
• Pre-op/ pre-procedure preparation of patient
• Admission
• Discharge
• Patient evaluation- initial during admission
• Transfers
• Bedside procedures
• Specialized procedures
It is in this step that a map of present workflows at Hospital X will be analyzed; identifying defects such as bottleneck, redundancies, human intense activities, delays, completion barriers and failure points. Changes in technology, workflows and timeliness of information for clinical decisions, as well as minimizing transcription errors leading to safer patient care, deserve to be explored (Yeung et. al. 2012).
This workflow analysis will serve as a baseline for each patient encounter, domain or process. This baseline can identify:
• Time taken per task
• Labor resources per task
• Data or information needed to complete task
• Data to be generated per task
• Obstacles to receiving information
• Errors that may occur in doing a particular task
The benefits of workflow analysis will be ensuring the hospital doesn’t apply a computer or IT solution to a broken process. Applying IT solutions will only exacerbate the problem rather than alleviate it.
d. Space Needed for Workstations/Hardware
i. Inpatient
Within the 200 bed hospital facility there are ten individual nursing units and an Emergency Department with thirty more beds. Each bed within the hospital and the thirty beds in the ED will each require a computer for EMR access. This will be done using a “workstation on wheels” or WOW. Each WOW requires three feet of space. There will also be ten desktops installed on each unit at the nurse’s stations and ten desktops in the ED. Each desktop will also take up about three feet of counter space, which is already present within the nurse’s stations. There will be twenty desktops dispersed throughout the facility in locations such as physician lounges and sleep rooms for physician access as well. Each of these units will utilize three feet (Campbell, Kramer, Kelsey, & King, 2014).
ii. Hospital-Based Clinic
The hospital based clinic has twelve rooms and will need twelve WOWs, one for each room. The clinic will also use ten desktop computers distributed throughout the administrative areas and the physician offices. Each WOW and desktop will consume about three feet of space (Campbell et al., 2014).
iii. Outpatient Clinics
Each clinic throughout the community will install twenty WOWs, one for each exam room and twelve desktops to be utilized throughout the administrative areas and the physician offices (Campbell et al., 2014).
iv. Servers
Each location will require the installation of a server to connect the integrated system. Each server will require about 100 square feet of room. This room will be accounted for with the removal of paper charts after the conversion to the EMR (Smith, 2003).
e. Roadmap and Timeline
It is the outline of Hospital X’s pathway to selection of and implementation of electronic medical records. It is a guide in evaluating systems and making a final selection and negotiating the agreement. The proposed EMR implementation will be an extended project. Ensuring that the system is implemented in a timely manner it is a must to establish a realistic timetable. Proposed GO LIVE is NOV 30, 2017.
The timelines and scope of hospital phases that lead to the go live will occur over a 12 month period that will include tasks such as project planning, design, and build phases. The physician clinics will be implemented once the main hospital is complete. It is anticipated that the training will be scaled down versions of the hospital phases for each clinic.
January 15, 2016 Phase I
Pharmacy, laboratory and radiology
April 15, 2016 Phase II
Document Imaging, clinical data repository, registration and scheduling
August 1, 1 2016 Phase III
Clinical documentation, surgery, ICU, ER, medical records charts, electronic medication and scanning and administration record.
November to December 2015
• Obtain support from hospital leadership
• Submit request for proposals (RFPs) and review submissions
• Create a shortlist and choose vendor
• Plan implementation, training, and provisioning
• Assess current project management
April to May 2016
• Appoint a project team and define roles and responsibilities
• Develop workflows for automating documentation and manual entry
• Plan processes for migrating paper information to the system
• Review database and assess infrastructure
• Define templates and data elements
• Create list of chief complaints and necessary data elements for billing and patient encounters
• Provision necessary hardware and software needs
June to July 2016
• Install hardware
• Create communities of referrals
• Customize and review templates
• Evaluate readiness of physicians and nurses
• Schedule training of staff and additional training for super users
• Reconcile installation timeline with vendor’s timeline
• Notify patients about new system, provide an overview of the benefits, and request feedback from patients of thoughts or concerns
August to September 2016
• Build and test interfaces
• Test readiness system
• Populate patient records
• Adjust patient schedules
• Adjust staff schedules
• Communicate schedule to staff
October 3, 2016
• Customize templates
• Reduce patient load
• Assess and recheck system, workflows, etc.
• Meet with staff midday and day’s end to gather feedback
November 30, 2016 GO LIVE!!!! Staffing numbers for both nurses and physicians will be increased during the first two weeks of implementation.
December 2016 to February 2017
• Compare templates of providers in system
• Build a common internal dictionary of own terms
• Share protocols among clinicians
• Create a network for support and feedback with other hospitals and organizations
• Communicate with vendor about questions, concerns, or bugs

f. Staff Training
Training delivery will be aligned with go live milestones with flexibility or changes. Staff will attend training prior to being granted access to the system and as part of any system upgrade. All clinical staff will be required to attend all training and demonstrate competency on the EMR functions relevant to their role. The methods in which instruction will be delivered include:
? Web-based tutorials, most appropriate for higher level, more general concepts
? Instructor-led classroom training workshops, facilitated by clinical subject matter experts as well as training team members with expertise on the EMR functionality to be covered
? One-on-one short training sessions with physicians for each phase of the project led by super users, focused on clinical care and efficient interactions with the EMR applications
? “Just-in-time” refresher workflow and EMR sessions in the time frame very close to the go live milestone for the implementation phase
? On-request support for assistance or clarification during the time frame right after go live
? Training on advanced features and new enhancements in post go live and ongoing timeframes, offered as appropriate in web-based or instructor-led methods
There will be multiple ways that the team will distribute the education materials used in these sessions, as well as user guide documents and “tip sheet” flyers designed to be readily available for quick reference while the user is at a workstation. Posters will be placed in the staff work spaces to provided reinforcement of mission and vision, and reminders where to find more information on the hospital intranet and how to contact the right resources to answer questions (Lopez et.al 2011).

g. Communication Plan
The proposed communication plan of HOSPITAL X will recognize that EMR implementation is more than a technical endeavor and therefore must consider the substantial impact on the organizational staff. The goals of the communication plan will therefore include: demonstrating the need for the rationale behind EMR implementation, allaying fears, encouraging and facilitating participation, creating and maintaining enthusiasm for the project and anticipating and or averting obstacles. This communication plan will be well in place one year from GO LIVE.
h. Proposed Hospital X Governance Structure
i. Cultural and Literacy concerns
In order to make the transition to EMR a smoother one, nursing and hospital leadership must be involved in creating a receptive and excited culture for the change. Prior to the implementation, hospital leadership should survey the impacted units and get feedback on their general attitude towards and concerns about a shift to an EMR (Edwards, 2012). By identifying staffing concerns before the implementation, leadership can work to address those concerns before presenting the product to the staff. It is important for nurse leaders to show the staff (including nurses, physicians, and all other interdisciplinary team members) the positive affect EMRs will make on the hospital.
It is also important for staff to feel included in the design, implementation, and support of the EMR. Edwards (2012) states that end user satisfaction is one of the biggest determinants to the success of a change. In order to ensure end user satisfaction, it is suggested that end users be included in the development, training, and implementation of the EMR. During an implementation at another institution, the use of end users were included during planning and development and it lead to “optimal efficiency in creating a smooth cultural transformation” (p. 112).
VII. Conclusion
Electronic Medical Record implementation for our organization would be the next logical step. The implementation, while costly up front, will provide increased patient safety, decreased sentinel events, increased communication throughout the system, and increased revenue and growth potential. Using a vendor such as EPIC with a proven track record and implementation and training support seems to be the best option. The growth potential for our business within a quickly growing industry is immense and the implementation of an EMR would be beneficial to the company.

References
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Thompson, D., & Fleming, N. (2008). Finding the ROI in EMRs…electronic medical record. Hfm (Healthcare Financial Management), 62(7), 76-81 6p. Retrieved from http://library.gcu.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true &db=ccm&AN=105698961&site=eds-live&scope=site
Uslu, A., & Stausberg, J. (2008). Value of the electronic patient record: An analysis of the literature. Journal of Biomedical Informatics, 41(4), 675-682 8p. Retrieved from http://library.gcu.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true &db=ccm&AN=105664256&site=eds-live&scope=site
Yeung, M. S., Lapinsky, S. E., Granton, J. T., Doran, D. M., & Cafazzo, J. A. (2012). Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units. Journal of Clinical Nursing, 21(7/8), 975-982. doi:10.1111/j.1365-2702.2011.03937.xttp://library.gcu.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=73176135&site=ehost-live&scope=site
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