The Electronic Health Record:
Technology that is Transforming Nursing Practice
Over the past decade, technological advances have paved the way for nurses to provide, quality, safe, standardized and individualized patient care (Saba & McCormick, 2015). The use of the Electronic Health Records (EHR) to manage patient data is quickly becoming widespread in the healthcare industry. The emerging use of the Electronic Health Record, is transforming how nurses care for patients. By creating and implementing an electronic, comprehensive, standardized method of recording patient data, nurses can facilitate and coordinate patient care with members of the multidisciplinary healthcare team. The use of the Electronic Health Record will promote positive
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Functional Purpose of the Electronic Health Record
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006). Key Features of the Electronic Health Record for
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To effectively use the Electronic Health Record, the nurse needs to have knowledge of technology in addition to clinical competency (Linder, e.tal, 2007). This is a common barrier of implementing the Electronic Health Record. Initially, the conversion from paper charting to electronic charting is frustrating, this is particularly an issue for veteran nurses. Veteran nurses are use to a routine, documenting in pen and paper is the only method of documenting they have ever experienced. Nurses are trained and educated with a protocol-based and systematic methods of caring. The implementation of the Electronic Health Record presents a change in the way nurses care for patients (HIT, 2015). Veteran nurses that have worked in the healthcare system for over 30 years and have always used paper charts, now have to re-learn how to chart with the Electronic Health Record (Anders & Daly, 2010). Understanding the nursing related barriers of implementation of the Electronic Health Record is
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
The main purpose of EHRs is to mainly exchange health information electronically to help improve quality and safety for patients. Four pros of EHRs is to provide accurate and recent information of the patients, allow for quick access to the patient records, share the health information securely, and make patient records and notes legible. These four points are important and necessary because the goal overall is to improve public health. Patient information should always be updated and current. Health professionals need to easily have access to patient records to either update them or verify the information. Also, health professionals can now avoid any discrepancies with electronic records verses when records were completely on paper.
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
Advances in technology have influences our society at home, work and in our health care. It all started with online banking, atm cards, and availability of children’s grades online, and buying tickets for social outings. There was nothing electronic about going the doctor’s office. Health care cost has been rising and medical errors resulting in loss of life cried for change. As technologies advanced, the process to reduce medical errors and protect important health care information was evolving. In January 2004, President Bush announced in the State of the Union address the plan to launch an electronic health record (EHR) within the next ten years (American Healthtech, 2012).
In the 2004 State of the Union Address, President George W. Bush stated “within the next 10 years, Electronic Health Records (EHRs) will ensure that complete health care information is available for most Americans at the time and place of care (U.S. Government)”. In order to encourage the widespread implementation of EHRs and to overcome the financial barrier to doing so, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 set aside $27 billion in incentives to be distributed over a ten-year period for hospitals and healthcare providers to adopt the meaningful use of EHRs (Encinosa, 2013). In 2011, the Centers for Medicaid and Medicare Services (CMS) implemented the Meaningful Use (MU) Incentive Program. In order to qualify for incentive payments under MU, providers must attest to meeting specific quality measures thresholds each year consisting of three stages with increasing requirement at each stage.
Electronic health records is medical information recorded on computers, the data consists of a variety of data, medical history, medication, allergies, diagnoses, immunizations, labs, radiology, vital signs, billing information, and personal statistics weight and age. The EHR is designed to help with medical errors. It helps reduce errors with allergies to a medication. Also help with reading legibility and eliminate the lost forms and paperwork. It allows for the patients history to be viewed by several doctors. Doctors or nurses can update information on your record.
Retrieved from: Ashford University Library Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521.
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
The implementation of electronic health records (EHR) continues to make an impact on nursing and patient care throughout the country. As a part of the American Recovery and Reinvestment Act of 2009, all public and private healthcare providers were required to implement electronic health records in their facilities by January 1, 2014. By demonstrating “meaningful use” of the electronic medical record, facilities are able to maintain Medicaid and Medicare reimbursement levels. Providers who show that they are meeting the “meaningful use” criteria during EHR use will receive an incentive payment from Medicare and Medicaid. “Meaningful use” is “using certified technology in EHR implementation to improve quality, safety, efficiency, and reduce health disparities; engage patients and families; improve care coordination; and maintain privacy and security of patient health information” (Centers for Medicare & Medicaid Services, 2013).
There are a number of ways in which patient care can be improved with a facility that utilizes multiple charting systems. The simplest way to provide effective quality care is to implement the EHR. A EHR is an electronic system consisting of a complete patient medical health history of past and current conditions (Keller, 2016; Menachemi & Collum, 2011). In addition, to the patient’s demographic, diagnoses, medications, treatment plans, allergies, laboratory data, immunizations, and test results. EHR decreases medical errors such as misinterpretation of clinical notes, doctors orders, not having access to paper chart that have yet to be filed or has been missed file (Keller, 2016). EHR also allows for quick and easy access to diagnostic test results and patient notes that are needed for patient care. EHR will significantly enhance patient care by reducing the amount of time it takes the healthcare team to retrieve the needed health information to deliver patient care. It will also dramatically reduce medical errors that are associated with the nursing staff manually entering doctors’
Technology is stated as the scientific method and material used to achieve a commercial or industrial objective. To go one step further, nursing technology is using a tool to advance nursing practice. “The Institute of medicine identified that technology as a viable method of enhancing patient care delivery and improving staff productivity” Sensmeier, Horowitz (2003 page). Because inadequate nursing staff causes shortcuts to be taken, there are mistakes made that could have possibly been prevented. Errors by nursing staff were variously reported as being responsible for between 44,000 and 98,000 hospital deaths per year. Sensmeier, Horowitz (2003). Technology can have a large impact on nursing. In the past 5 to 10 years, computerized patient records have increased less than 10%. This number shows us that we are still not embracing technology to its full potential. Today in most hospital systems computerized electronic charting is being used. Many hospitals have many different systems for...
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.