Health IT Hot Topic: Electronic Health Records Vivien Grayson NR 512 – Nursing Informatics 08/17/2016

Introduction

• Paper vs. Digital Records: The shift from paper-based to digital health records marks a significant evolution in healthcare. While paper records require physical storage and manual retrieval, electronic health records (EHRs) provide a more efficient, accessible, and comprehensive approach to managing patient information.
• Components of Electronic Health Records (EHRs): EHRs encompass a wide array of patient data, including medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory test results.
• Special EHR Features: EHRs offer features such as clinical decision support tools, electronic prescribing (e-Rx), and integrated patient portals, which allow patients to access their health information, communicate with their healthcare providers, and actively participate in their care.
• Paper Chart Retrieval Process: Unlike digital records, retrieving information from paper charts can be time-consuming, prone to errors, and involves physical storage space. EHRs eliminate these issues by providing instant access to patient data.
• Patient Involvement in Care: EHRs empower patients to engage with their health information through patient portals, where they can view their medical records, schedule appointments, and communicate with healthcare providers.
• Homestead Hospital Patient Portal: At Homestead Hospital, a dedicated staff member assists patients with accessing the patient portal. Upon admission, patients receive a PIN via email, which they can use upon discharge to access their medical information securely.

Impact on Practice

• Nursing: EHRs have transformed nursing practice by streamlining data collection, improving the accuracy of nursing assessments, and ensuring that nursing needs are met efficiently. Nurses can quickly access actionable information, such as patient histories and medication lists, to make informed decisions.
• Nursing Informatics: EHRs are a cornerstone of nursing informatics, integrating technology into nursing practice to enhance the quality of care, improve patient outcomes, and optimize healthcare processes.
• Data Collection: EHRs facilitate comprehensive and accurate data collection, enabling nurses to document patient care in real-time and access historical data for better care planning.
• Nursing Needs: EHRs address nursing needs by providing tools for patient monitoring, documentation, and communication, all of which contribute to safer and more effective care.
• Actionable Information: Nurses can use EHRs to access actionable information, such as alerts for potential drug interactions, reminders for preventive care, and updates on patient conditions, which support timely and informed decision-making.

Impact on Patients & the Community

• Safe and Efficient Practice: EHRs enhance patient safety by reducing the risk of errors, such as medication mistakes or miscommunication, and improving the efficiency of healthcare delivery.
• Patient Education: Through patient portals, EHRs provide patients with access to educational resources, helping them understand their health conditions and treatment plans, which promotes better self-management.
• Safer Patient Care: EHRs contribute to safer patient care by tracking allergies, medications, and potential interactions, ensuring that healthcare providers have access to comprehensive and up-to-date patient information.

Pros and Cons of EHRs

Pros:

• The Six Rights of Medication Administration: EHRs support the “Six Rights” (right patient, right drug, right dose, right route, right time, and right documentation) by ensuring accurate medication orders and reducing the risk of errors.
• Current and Complete Medical Records: EHRs provide a single, current, and complete medical record for each patient, which can be accessed by authorized healthcare providers across different settings.
• Evidence-Based Practice Compliance: EHRs facilitate adherence to evidence-based guidelines, improving the quality of care and supporting clinical decision-making.
• Litigation Support: EHRs create a clear and comprehensive documentation trail, which can be valuable in legal cases involving patient care.
• Eco-Friendly: By reducing the need for paper records, EHRs contribute to environmental sustainability.
• Electronic Prescribing (e-Rx): EHRs enable electronic prescribing, reducing the risk of prescription errors and enhancing medication safety.

Cons: While not detailed in the provided content, potential cons of EHRs might include challenges such as high implementation costs, concerns about data security and patient privacy, potential disruptions during the transition from paper to digital, and the need for ongoing training for healthcare providers.