An electronic health record (EHR) is termed as a patient’s medical or paper chart in a digital and secure format. EHRs are an innovative and unique form of technology in the healthcare system wherein authorized users can access patient-centric information in real-time. EHRs are known to contain conventional clinical information of the patients. It includes medical history, current treatment and management interventions, current medical status and other personal information. However, EHR should not be restricted to clinical or patient-centric information but also vital information that could be of use at the healthcare provider’s office. In the nursing profession, the EHR is known to contain the following: (a) Patient’s clinical information such as medical history, diagnosis, treatment and management plans, medications, and follow-up protocols (b) It also contains information such as lab and tests results, radiological images, allergy information, and immunization dates (c) Healthcare providers can access evidence-based protocols and tools in order to make comprehensive and effective clinical decisions (d) Nursing professionals can use EHR systems by implementing key words in order to automate and streamline workflow within the clinical setting. The major advantage of the EHR system is that patient information can be shared instantaneously by authorized users across various healthcare organizations without the risk of being lost of corrupted. The digital format is secure and error free that helps in faster healthcare delivery, especially in emergency care. The EHR system can be implemented across cross-platforms that can be shared within specialist, laboratories, pharmacies, medical imaging centres, schools, emergency facilities, and workplace clinics. (Russo E, et al. 2016)
Electronic Health Records in Healthcare and Nursing: The EHR-based system has played a vital role in healthcare and nursing profession. Some of the key areas wherein EHR has helped within the nursing profession include: (a) Improved medical management with the help of organized and scheduled systems which link with appointments, progress notes, and managed clients through automated coding (b) Improvised and faster healthcare delivery with the help of chart management (centralized), health and patient-centric queries, and other vital shortcuts (c) Faster, improved, and secured access of patient information across labs, healthcare partners, clinicians, and emergency care unites (Whalen K, et al. 2016). The nursing fraternity has observed key factors that have led to the success of the EHR-based system such as (i) Access to patient information virtually anywhere and anytime (b) Live tracking of medical information including those from hospitals, clinicians, labs, and staff members (c) Health plan auditing with secure and compliant coding systems (d) Diagnostic images, results, and vitals including costs, order, and receipts (e) Healthcare provider and nurse access to vital information across cross platforms based in registries and government-based healthcare systems (Ellaway RH, Graves L, Greene PS. 2013).
Based on current evidence and a national survey from healthcare professionals on the EHR system, the following facts have been enlisted: (a) The efficiency of healthcare providers has increased by 79% with the implementation of an EHR system (b) 83% of nursing and HCPs claimed that e-prescription has saved time and effort (c) HCPs who have adopted an EHR system claim that 68% of the physician recruitment is based from EHR (d) Lab results and diagnostic modalities delivery has increased by 75% with the help of EHR (e) EHR-based systems help in data security and confidentiality by 70% compared to conventional healthcare systems (Russo E, et al. 2016 and Ellaway RH, Graves L, Greene PS. 2013).
EHR and nursing coordination: Based on current evidence, an EHR-based system has help in enhancing care coordination with the help of care fragmentation. Patient health information can be circulated within a few minutes across platforms through the EHR system. The main objective of the EHR system is to provide faster and secure healthcare delivery. For example, an EHR would help in notifying HCPs of the patient in the event of hospitalization or emergency care facilities. Since the EHR facilitates real-time tracking of the patient, HCPs associated with the patient can access up-to-date information about the patient. The EHR-based system has been useful for nurses in care coordination who have (a) multiple specialist (b) repeated and frequent change between care settings and (c) treatment and management across multiple settings including emergency care. The major advantage of HER-based system is that it helps in reducing medical records and unwanted diagnostic tests. It helps HCPs in analysing the current status of the patient along with treatment or underlying health conditions that may or may not have been treated by another specialist. The EHR-based system thus helps in providing improved quality care of patients, patient outcomes along with enhance care coordination by nursing professionals (Whalen K, et al. 2016)
EHR and patient care: Based on current evidence, the EHR-based system has filled the gaps with healthcare provider and patients within the healthcare system. Over the years, the electronic system has helped in reducing timelines, patient outcomes, and faster responses in critical situations. Some of the key factors that should be considered include: (a) Improve accuracy and clarity on medical records along with reduction in medical errors (b) Reduced duplication of tests along with secure, fast, and accurate availability of patient information (c) Reduced delay in treatment and management (d) Informed patient and better health outcomes and (e) Improved and faster care provision in emergency (Russo E, et al. 2016).
Electronic Health Record: Personal Experience: The EHR system is available in most developed nations. Based on my experience, the EHR-based system is known to have many positives and negatives (Whalen K, et al. 2016). A key positive is that the EHR is available across various organizations and thus fastens the process of healthcare delivery. Example: My aunt who is diabetic with hypertension was referred to a dietician for a diet control program. Her health records were made available to the dietician which facilitated better healthcare intervention since it helped in easy assessment of past and current medical history along with treatment strategies (Ellaway RH, Graves L, Greene PS. 2013).
A key negative about the EHR-based system is that it is tech-based and relies on internet and other connectivity protocols. The EHR is known to provide a robust and fast process to access patient information (Whalen K, et al. 2016). However, it was witnessed that in an emergency care situation, a patient’s medical history records could not be accessed due to connectivity issues. The major flaw in the access issue was the lack of connectivity owing to internet issues. This led the emergency care staff to take in quick actions in assessing the patients vital and depend on conventional strategies for quick response care. Unfortunately, it is beyond human boundaries to control technical issues such as internet or connectivity loss which can have a major impact on healthcare delivery (Russo E, et al. 2016).
Conclusion
The nursing profession has adopted and adapted the EHR system in order to facilitate improved and informed care. The main objective of nursing professionals is to provide improved health outcomes and patient satisfaction (Whalen K, et al. 2016). Nurses have developed a sense of trust and faith on the new and improvised EHR system. It influences other healthcare professionals to implement and support patient-focused care and support. The cost involved in implementing an EHR system is high but is advantageous over the long run since it reduces time, effort, and increases the potential of patient care services within an organizational setting (Whalen K, et al. 2016)
Influence on nursing career
Many universities and colleges have incorporated EHR systems as part of the curriculum in order to facilitate innovation and technology among new nurses. The University of California, San Francisco and the NANDA international have recognized the potential of EHR based systems. By 2020, the EHR system would most likely be part of all nursing programs and would also facilitate improvised and robust care among nursing professionals.
References
Ellaway RH, Graves L, Greene PS. Medical education in an electronic health record-mediated world. Med Teach. 2013 Apr;35(4):282-6.
Russo E, et al. Challenges in patient safety improvement research in the era of electronic health records. Healthc (Amst). 2016 Jul 26. pii: S2213-0764(15)30090-7.
Whalen K, et al. Analysis of Nursing Clinical Decision Support Requests and Strategic Plan in a Large Academic Health System. Appl Clin Inform. 2016 Apr 13;7(2):227-37.
