Nursing Informatics: Electronic Health Records

Introduction

Over the past few decades, great strides have been made in health care technology. Nurses have been in the forefront in the development and implementation of health care technologies in hospitals. One important development in the field of nursing is the electronic health record (EHR). The technology supports integrated data that are useful in clinical decision-making and inter-professional data sharing. This paper examines EHR and its significance to nursing students with a research interest in this topic.

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Description of the Topic

Definition

An EHR is an automated health record that contains a broad range of patient information, including “demographics, progress notes, health problems, medications, medical history, and vital signs”, among others (Kelley 15). Its aim is to transform decision-making and facilitate data sharing within clinical settings. Therefore, students interested in EHR should seek to understand its theoretical grounding, uses, and benefits to patients, nurses, and physicians.

Nursing Theories and EHR

The EHR technology is grounded in nursing theories that provide a framework for the integration of technology in nursing care. One such theory is the systems theory, which focuses on the “interacting parts within boundaries” (Kelley 16). The electronic health record utilizes the patients’ body systems and technology to improve patient care (Kelley 16). In contrast, the cognitive theory relates to health information processing, which is the central aim of EHR. Additionally, both input and output data involve some learning processes.

Meaningful Uses of EHR

The main value of EHR systems in health care is that they allow providers to obtain a broad range of patient data to improve the efficiency of hospital processes. It allows the management to access data for billing, the doctor to assess the efficacy of treatments, and the nurse to monitor patient progress. Therefore, EHR provides integrated data that are useful in providing quality patient care.

The Centers for Medicare and Medicaid Services encourages providers to use certified EHR products in a meaningful way to promote health care quality, safety, and coordination (par. 3). The agency also provides incentives to hospitals that utilize EHR to share health information and report clinical quality indicators (Nickitas and Kerfoot 142). Nurses often use EHR in drug formula checks to reduce medication errors. EHR also helps nurses to analyze different lab test results or data and thus, make better clinical decisions.

Nurses can also use the technology to retrieve the health information of patients with a particular disease or condition. Certified EHRs provide additional information about the patient’s health literacy. This function is essential in providing appropriate educational resources to the patient. An EHR can also be used to reconcile medications taken by patients, develop transition of care summaries, and maintain immunization records (Nickitas and Kerfoot 146). The EHR technology has the capability to maintain electronic health records and diverse patient data. Thus, it is a useful tool for reporting lab results to regulatory bodies for the purposes of disease surveillance.

The computerized provider order entry (CPOE) is an EHR technology that allows physicians to provide treatment instructions in an electronic format, which reduces medication errors and improves nursing workflow in hospitals. Electronic records also allow nurses to track patient allergies related to drug interactions and provide optimal care. Since the EHR contains patient demographics, medical history, and assessment data, it serves as an essential clinical support tool. It enables clinicians to make accurate diagnoses and provide appropriate treatment.

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The EHR enables nurses to maintain a medication record for each patient throughout the hospitalization period. Tracking changes in a patient’s condition by constantly monitoring vital signs is another important use of the technology. According to the Centers for Medicare and Medicaid Services, nurses can also monitor “smoking status for respiratory patients aged over 13 years” (par. 9). EHR also allows practitioners to provide self-care instructions and other information to discharged patients. Reporting hospital quality indicators to regulatory bodies is another key function of the EHR. It allows nurses to track and report medical errors and patient fall incidences. This provides benchmark data for continuous quality improvement. EHR also facilitates electronic sharing of patient information with authorized providers to facilitate care transition and referrals.

The Key Components of EHR

EHRs combine different ancillary services to provide integrated data for improving nursing care. One such component is the administrative system, which encompasses patient “registration, admission, discharge, and transfer data” (Nickitas and Kerfoot 144). This information is useful in clinical analysis, patient identification, and transition care. Each new patient is assigned a unique identifier during registration. Any information related to the patient is linked to this identifier. Therefore, diagnoses and lab tests related to the patient can be retrieved from the EHR using the identifier.

The second EHR component is the laboratory system that contains data related to lab tests. It links administrative information, such as schedules, with laboratory data. The system is compatible with most test instruments, which makes automated diagnosis and assessment possible (Nickitas and Kerfoot 144). The third component is the radiology system, which links images (x-rays) to the other patient data. This allows nurses to track patient progress and communicate results to physicians. In contrast, the pharmacy system helps in prescription and pharmacy ordering. The computerized physician order entry (CPOE), which is a major component of the EHR, enables providers to “order laboratory, pharmacy, and radiology services” (Nickitas and Kerfoot 145). The system helps prevent medication errors to enhance patient safety.

Clinical documentation is another key component of the EHR. It captures a wide range of patient data, including assessments, clinical reports, and diagnoses, among others (Nickitas and Kerfoot 145). It allows electronic documentation of nurse’s notes, work flow sheets, discharge summaries, living wills, medical records, and staff credentials, among others. The EHR components provide integrated data that are useful in bedside care.

Reasons Why this Development is Important

It is evident that the EHR has many direct benefits to patient care. It is obvious that EHR is an important health technology because of its ability to support patient-centered care. EHR facilitates the integration of patient information and clinical services, making patient care safer and effective. With the help of EHR, time-consuming paperwork is eliminated, which provides nurses more time for bedside care. Additionally, it is evident that EHR maintains comprehensive data on each patient. This eliminates time wastage, as nurses are able to access all patient data from the integrated health records.

An indirect benefit of an EHR system is that it fosters partnerships between providers through data sharing. Thus, it enhances continuity of care, which translates into better patient outcomes. The use of electronic records improves patient care through the “electronic access of care pathways and protocols” (Kelley 15). This leads to evidence-based care in the nursing practice. Additionally, electronic records are more legible than written documents. Thus, the use of EHR reduces medical errors, which contributes to improved patient safety. It also ensures better information that enhances the quality of clinical decisions.

The benefits of EHR go beyond primary care. Besides improving direct patient care, EHR provides data for other hospital processes. In particular, it enhances clinical governance by providing an evidence base for quality improvement in hospitals. Another less obvious reason why EHR is important to the organization relates to its capability to support audit and staffing issues. Based on the quality indicators, it is possible to evaluate staff performance and identify staff training needs. Additionally, electronic records provide primary data for epidemiological and clinical research. The evidence generated from the research helps formulate hospital interventions and policies to address public health problems.

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EHR enhances the clinical management function in many ways. It captures cost data, including costs related to medication, specialist care, and inpatient services, among others. Electronic records also facilitate bed management to ensure optimal occupancy. Another less obvious benefit of EHR to the hospital is its role in risk management. The integrated data records help reduce adverse events associated with medication errors. The management can also use patient data to benchmark a hospital’s quality improvement initiative.

Considerable reductions in nursing staff time can be made when using EHR. According to Kelley, electronic records can save up to “one hour of nursing staff time per shift” (17). The use of EHRs also enhances workflow management and clinical processes. The improvement in workflow stems from the fact that physician entries are done instantly. Furthermore, electronic records allow physicians to make legible and complete order entries. This reduces the amount of time nurses take to fill in incomplete orders.

An EHR is an interactive patient tool that allows nurses to develop an efficient workflow plan to reduce time wastage and avoid role duplication (Kelley 16). In this regard, it promotes the efficiency and effectiveness of nursing practice as efficient workflows allow more time for bedside care. Additionally, it provides integrated data to other health care professionals, which promotes interdisciplinary collaboration within the hospital setting. Nurses, physicians, pharmacists, and lab technologists have instant access to the patient data stored in health records. Nurses can use the patient information captured by the electronic health records to formulate individualized care plans. Thus, patient-centered care is possible with electronic health records.

Physicians also benefit from the use of EHRs. It simplifies the task of making and maintaining patient records by eliminating much of the paperwork. Additionally, it improves physician ordering and communication with other health care staff. Electronic records are less prone to errors than written documents because they are legible. Thus, the use of electronic records, particularly the CPOE, significantly reduces the risk of adverse events. Additionally, less time is spent to complete electronic orders than to record each entry in medical documents.

Conclusion

Nursing informatics entail the use of health care technology such as the EHR. Electronic health records provide integrated data that nurses can use to support safe and patient-centered care. The technology has direct benefits to the patients and the nursing practice through improved workflow efficiency. The EHR’s less obvious benefits relate to improved provider partnerships, continuity of care, and hospital management functions.

Works Cited

Centers for Medicare and Medicaid Services 2015, EHR Incentive Programs: Certified EHR Technology. Web.

Kelley, Tiffany. “Opportunities for Nurses in the Era of Electronic Health Records”. Open Journal of Nursing 4 (2014): 15-17. Print.

Nickitas, Donna and Karlene Kerfoot. “Nursing Informatics: Why Nurse Leaders Need to Stay Informed.” Nursing Economics 28 (2012): 141-158. Print.

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StudyCorgi. (2020, May 17). Nursing Informatics: Electronic Health Records. Retrieved from https://studycorgi.com/nursing-informatics-electronic-health-records/

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