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Electronic Health Records (EHRs)
Electronic Health Records (EHRs)
EHR or EMR (electronic medical records) are used interchangeably as a generic term to refer to an electronic version of a record of a single treatment episode, or the information system in which it resides. The term has evolved to refer to a comprehensive, birth-to-death record of all health information and treatment encounters for an individual—something that has yet to be realized in a healthcare delivery system that still, in 2016, remains highly fragmented with separate records at hospitals, clinics, urgent-care centers, public-health offices, long-term care facilities, subacute care, and doctors’ offices. The realization of a birth-to-death record promises many benefits, not the least of which is improved access to information, continuity, and quality of care. Both Presidents George W. Bush and Barack Obama called for the establishment of an EHR for every American as a means to improve care across the life continuum and to help transform healthcare delivery. The target date of 2014 for that goal will not be met, although progress has been made.

Electronic record systems are built around large databases that allow input, storage, and retrieval of specific data for use in a meaningful way that can support other functions, such as decision support, results reporting, and order entry. Clinical documentation and clinical messaging are other basic functions. Use and reuse of data relies upon the collection of structured data that follows a format that supports manipulation.

Historically, automation started with a limited number of functions, such as patient registration; then, it expanded to include clinical systems, which grew to share laboratory, pharmacy, and radiology information. Clinical documentation began with simple elements, such as vital signs and intake and output, before the incorporation of “nurses’ notes” and progress notes. Order entry first automated a paper process in which physicians wrote orders on paper charts for transcription into the computer by clerks and nurses—a process subject to errors until it was replaced by computerized provider order entry, or CPOE, a system in which providers enter their own orders. Realizing the benefits associated with the EHR requires structure provided through standardized languages and health-information exchange (HIE). As we discussed in Week 3, standardized languages support clinical decision support, research, communication, and information sharing.

Reflection

1.Have you ever wondered why a field on a computer screen only accepts certain characters or a limited number of characters? This is an example of screen design to force entry of structured data. Another example is providing predetermined choices rather than allowing users to enter free text. Can you see advantages or disadvantages with this approach? What might these be?

 

2.How Do EHRs Support the Information Needs of Nurses?
EHRs collect, store, and permit retrieval of clinical information in a legible format,often while supporting views customizable by each user. Additional support for direct-care providers can be seen with clinical alerts, decision support, and the integration of evidence-based guidelines for care. EHRs can also incorporate links to resource materials and databases that allow users to quickly and seamlessly view information about the patient’s condition without exiting the EHR (Cimino, Jing, & Del Fiol, 2012). The bulk of users rely upon clinical data needed for the direct provision and documentation of care, but what other information might EHRs provide?

The creation and use of structured fields support legal, accreditation, reimbursement demands, the collection of core criteria for Meaningful Use, and disease and procedure code information,some of which can be tied to specific patients, while other data such as that collected for Meaningful Use is stripped of patient identifiers. Some of you use reports generated from your clinical systems and EHRs, either on demand, monthly, or on an annual basis using various criteria such as MRSA status, payer status, or a number of other criteria. While these reports can be very useful, they are not always easy to obtain or available when timely decisionmaking is needed.

Reflection

3.Can you think of information that you would find useful in a report that is not currently available to you? Is it information collected by your electronic record system? If not, could you see a way that it might be collected and made available? What is this information, and how could it better support your work and the care that you provide? How might you determine if you could access this information?

 

The healthcare sector is just beginning to realize the potential value of the large pools of de-identified data at its disposal. This aggregate data, also known as secondary or big data, can be used to improve care, discover patterns, reduce costs, support research, and identify and respond to consumer preferences. The process of tapping this data is known by many names—analytics, data mining, knowledge discovery in data bases, or business intelligence. The end result is that the analysis provided can support better and timelier decision making, decrease risks, and discover valuable insights as long as appropriate tools are used. Harper (2013) suggested improved staffing models based upon patient information as one potential application for nurses.

Reflection

Can you think of some other ways that secondary data can support nurses?

 

Good use of secondary data requires (Mantalvo, 2013)

good data quality;
leaders who recognize and are willing to support the use of secondary data;
appropriate technical infrastructure;
a culture that supports secondary data use and informed decision making; and
value to the data.
Another requirement for good use of secondary data is that it be available in a manner that is meaningful to those who need it and in a timely fashion to support informed decisions. Enter dashboards. Dashboards are a decision-support tool that graphically represents data in a manner that is easily understood. Dashboards can be adopted for clinical displays as well as use in the executive suite.

 

More potentially valuable information exists in an unstructured format in narrative clinical documents. This resource may be available in the near future with the adoption of a technical information exchange standard (Harper, 2013).

Patient-Care Information Technology: Nursing Informatics
Technology and the informatics skills required to support patient care is growing exponentially, and it would seem that its applications are limited only by one’s imagination. Applications range from the relatively “low tech” to extremely complicated. Consider some of the following examples already in use that serve to save labor and supply information that supports care and documentation. Consider where informatics skills might be used in each instance:

Monitoring technology. Digital monitors measure vital signs, heart rate and rhythm, and other parameters and can directly input those values into the patient’s electronic record. The addition of video and audio makes it possible to monitor patients at another location, whether that may be their home or at another facility.
Positive patient identification. Several technologies support identification of the correct patient and retrieve the associated record for further action, whether that is a lab draw, medication administration, or patient registration for a treatment episode. These technologies include barcodes, radio frequency identification (RFID) chips on patient identification bands, and biometric scans that use a unique trait such as fingerprint, palm print, retinal scan, or facial recognition to confirm identity.
Tracking. RFID technology tracks physical location of patients, staff, or equipment, making it quick and easy to determine location.
Barcode or RFID medication administration. These systems provide positive patient identification and assurance, and documentation of correct medication, route, dose, and time. Detailed information on staff usage and compliance with established policies is available.
Smart technology. This is integrated technology that saves time and work, and improves patient outcomes. Examples include intravenous infusion pumps that exchange information with pharmacy systems and barcode or RFID medication administration systems allowing infusion programming information to be sent directly to the pump at the bedside when the nurse scans the medication, thereby eliminating programming errors. A growing number of facilities have smart rooms, which incorporate RFID recognition of employee badges, announcing their name and role to patients as they enter rooms.
Voice recognition. Voice recognition allows staff to interface with the information system at the point of care and provides patients with hands-free access to the phone, Internet, bed controls, or television controls.
Mobile healthcare. A growing number of individuals use their smartphones as well as their computers for healthcare information and to manage their health, reporting glucose levels, suicidal ideation, weights, and VS, to name a few applications. Social media provides a means to announce services, provide support, and even conduct research.
Telehealth applications. Telehealth applications are

 

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