An electronic health record (EHR) is an electronic version of a patient’s paper record. EHRs are dynamic, patient-centered records that can be accessed only by those granted authorization. A patient’s medical and treatment history is stored in an EHR system. It is designed to go beyond the standard clinical data collected in a provider’s office and can be utilized to provide a more comprehensive picture of a patient’s care than is currently available.An electronic health record, which is considered a crucial component of health care delivery, contains a patient’s medical history, diagnosis, medication, treatment plans, immunization dates, allergies, radiographic images, laboratory and test results, and any other applicable information. It is necessary because it enables health care practitioners to use evidence-based tools to guide treatment decisions and to streamline and automate provider processes.
Moreover, electronic health records (EHRs) allow authorized practitioners to create and manage health information in a digital format that can be shared with other health care providers across numerous organizations and institutions. Medical imaging facilities, pharmacies, emergency departments, and clinics in schools and the workplace all use electronic health records to transmit health information (Yadav et al., 2018). This essay will provide a complete description of the EHR project, its outcomes, and recommendations for further improvement, among other things. In addition, the paper will include an in-depth discussion of the use of EHR by nurses in various healthcare settings, health-information designs appropriate for healthcare settings, use of EHR in interprofessional collaboration, and recommendations to improve the use of EHR in health care settings by nurses.
The Use of Electronic Health Records by Nurses
Electronic health records by nurses have gained their prevalence over the decades. Many nurses across several health care settings use EHR in their line of work. One of the ways nurses use electronic health records is documentation. The use of electronic health records (EHRs) can help improve patient safety, measure service quality, maximize efficiency, and estimate staffing needs by storing data. Additionally, they serve as a standard means of documentation that may be used by all members of the healthcare team (Baumann et al., 2018). Conversely, EHRs have the potential to reduce critical thinking and enable workarounds to evade forms. This might lead to errors or missing documentation if they aren’t appropriately utilized.
Despite that, nurses use EHR to prevent medical errors. Electronic health records (EHRs) can maintain track of patients’ prescriptions and allergies and alert clinicians to potential conflicts when a new medication is administered. Moreover, electronic health records are beneficial to nurses to improve patients’ health outcomes. With EHR, nurses can have access to all of their patient’s electronic health records can better understand the needs of patients who: have a specific ailment or are qualified for certain preventive measures (Baumann et al., 2018). It is possible to enhance patient outcomes through this EHR function, which assists healthcare providers in identifying and managing individual risk factors or combinations of risk factors in patients.
EHRs can also identify patterns in adverse occurrences and immediately alert patients at risk using this feature. Nursing staff can benefit from electronic health records in a variety of ways, including medication reminders, the prevention of drug interactions, instant access to a patient’s medical history, and the documentation of clinical treatment (Yadav et al, 2018).
Inter-Professional Care Team, Enhancing Workflows, Promoting Safe Practices and Quality Outcomes
EHR has been shown to enhance interprofessional collaboration and enhance interprofessional team care. The electronic health record (EHR) assists health professionals in coordinating patient care on an informed basis at any time and from any location; however, it only allows for asynchronous usage of patient records. Although the entire patient file allows for cooperative clinical decision-making based on shared data, the use of specialty- and discipline-specific user interfaces makes it difficult to communicate and interpret that data. Aside from that, not all critical information can be easily shared between things or even outside of the medical environment. It is perceived as a hindrance to collective responsibility for a seamless workflow because of the lessened necessity for face-to-face contact.
Electronic health records allow collaboration by systematically integrating patient data from many disciplines, resulting in a shared and comprehensive health record. Users can have simultaneous access regardless of time or place. This improves communication between medical experts, enabling them to work together more efficiently, and reduces the need for duplicative procedures like tests. As a result, medical professionals were dissuaded from using handwritten notes and local health records and encouraged to exchange their information instead. Collaboration is also made easier with the EHR, which makes it easier for several medical specialists to make joint clinical decisions, which is especially significant for long-term patients who many different doctors typically treat at the same time. With the EHR in place, hospitals can better collaborate because of the conditions it generates.
Through electronic physician orders and e-prescribing, EHRs enhance patient safety. The EHR supports computerized physician order entry, which is the process of submitting physician orders, including prescription orders, utilizing a computer or mobile device platform. Apart from that, HER supports the usage of electronic sign-out and handoff tools (Akhu‐Zaheya et al., 2018). Electronic sign-out solutions ensure that patient information is sent systematically throughout provider handoffs. According to two systematic reviews, using an electronic tool improved the handover process, decreased crucial patient information omissions, and decreased handover time. Additionally, bar code drug administration usage ensures the safety and improves patient results.
Bar code medication administration systems are computerized systems that use bar code technology to integrate electronic medication records. These methods ensure that the correct drug is provided to the valid patient at the appropriate time to avoid medication errors. Additionally, it’s worth mentioning that barcode systems vary in their sophistication—different systems, such as intelligent pumps. Electronic reporting, telemedicine, patient education portals, and electronic incident reporting have all been proved to have inherent benefits for patient safety. EHRs streamline workflow processes — that is, the flow of information within and beyond the chart. Numerous workflow activities are performed mentally and must be understood before selecting an EHR to do some of these tasks more efficiently. By contrast, paper charts do not empower patients in the same way that electronic health records do (EHRs). Electronic health records eliminate the need for paper charts while enhancing the quality and accuracy of existing data.
Strategic Planning for Health Informatics in Nursing
The majority of health-care organizations’ strategic plans aim to improve patient care quality. This is supported by the EHR effort, which aims to use EHRs to transform health care. The following advantages are provided by electronic health records: Improved health care through improvements in all aspects of patient care, including safety, efficacy, patient-centeredness, communication, education, timeliness, efficiency, and equity. EHR encourages the pursuit of the organization’s strategic plan. EHR facilitates cooperation by providing the data required for collaborative clinical decision-making among multiple stakeholders.
Organizations must adapt to the quickly changing health care environment and information technology improvements to utilize limited resources, meet the organization’s goals, and fulfill its mission. Just like the organizations, nurses must incorporate health informatics in strategic planning. Health informatics strategy systems will provide direction and purpose, helps identify the kinds of information technology needed, assist in the timely implementation of an information system that supports nursing, and identify desired outcomes and benefits of a system. In addition, the organization’s mission and business plan must be reflected in the nursing information systems plan, integrated into the overall information systems plan.
For the nursing strategic plan to be effective, it needs to include an assessment of the current environment to identify necessary technology, anticipated outcomes, environmental considerations, unique staffing or expertise requirements (Hersh et al., 2018). The nursing organization’s overall direction and purpose are spelled out in the nursing vision and mission statement. New technologies and automated methods of managing information can be applied to identify areas where new technologies and computerized methods can be used in the nursing organization. To ensure the plan’s success, it’s essential to identify any gaps in the organization’s existing staff and expertise that must be filled before moving forward with the plan’s implementation (Hersh et al., 2018). A set of goals or anticipated outcomes is developed based on the mission and the assessment results. There must be a clear set of attainable, financially feasible, and logistically feasible goals. Measurable objectives and detailed action plans can be developed from these goals when this part of the strategic plan is implemented.
Change management practices, such as involving those affected by the change and maintaining open lines of communication throughout the process, should be considered even from the strategic planning stage. The strategic plan should involve efforts to work with all relevant departments and provide input and educational opportunities to the various healthcare professionals. Finally, the strategic planning process concludes with a business plan outlining the mission, objectives, and strategies for particular system implementation (Hersh et al., 2018). It is possible to collaborate with other departments (in the organization) involved in this system to develop the strategic plan. The organization’s management and governing board receive information about the organization’s information system requirements via the strategic plan. An effective information systems strategy will allow nursing to make timely and better-informed choices when using information technology in the nursing department. The final effect of this planning should be a better use of information technology to serve the nursing vision and goal.
Recommendations to Improve the Current EHR
Several recommendations are offered in order to make the usage of electronic health records more convenient in the future. One of the recommendations is to put together a system for information governance. This method must be established in health care organizations to enhance health information supervision that includes top management and other important stakeholders must be developed by organizations. Furthermore, the organization’s health information management strategy must be aligned with the organization’s patient safety and risk management policies and procedures (Alotaibi et al., 2017). Another strategy is to look for potential safety hazards and address them. In addition, nurse leaders must identify areas in which health information technology can assist in improving patient safety, such as drug safety and adherence to clinical recommendations, and then implement those changes.
Similarly, making informed decisions is essential when putting electronic health records into place. It is the responsibility of nurses and their leaders to make an evidence-based decision and to examine the current information technology infrastructure (including software and hardware) in order to determine the cost-effectiveness of proposed technologies. Providing enough training for the proposed health information technology to all members of the appropriate line employees is also an extremely important suggestion (Alotaibi et al., 2017).
When implementing new technology, it is critical to do it in small steps to prevent disrupting existing processes and systems. This also contributes to the efficient use of electronic health records. Companies must review patient safety outcomes on a frequent basis to ensure that new technology has the desired effect. This is especially important during the first deployment period (Alotaibi et al., 2017). Moreover, in response to user feedback and patient safety outcomes, organizations should update and fine-tune the technology they have already established. Finally, health information technology must be updated on a regular basis to ensure that it reflects the most recent best practices in healthcare, regulatory standards, and technological stability.
Finally, electronic health record (EHR) is a digital record of their medical history, diagnosis, medication, treatment plans, immunization dates, allergies, radiographic images, laboratory and test results, and any other applicable information. EHRs are intended to facilitate the exchange of patient data between health care practitioners and organizations. The EHR enables computerized physician order entry and electronic prescription. Bar code medicine administration systems are bar code-enabled automated systems. EHRs eliminate the need for paper charts while enhancing the quality and completeness of existing data. Some recommendations are made in the future to improve the utilization of electronic health records. Making educated judgments is critical for successful EHR deployment. Organizations must monitor patient safety outcomes on a frequent basis, particularly during the initial implementation phase.
Akhu‐Zaheya, L., Al‐Maaitah, R., & Bany Hani, S. (2018). Quality of nursing documentation: Paper‐based health records versus electronic‐based health records. Journal of clinical nursing, 27(3-4), e578-e589.
Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi medical journal, 38(12), 1173.
Baumann, L. A., Baker, J., & Elshaug, A. G. (2018). The impact of electronic health record systems on clinical documentation times: a systematic review. Health Policy, 122(8), 827-836.
Hersh, W. R., & Hoyt, R. E. (2018). Health informatics: Practical guide. (7th ed.), Lulu. com.
Yadav, P., Steinbach, M., Kumar, V., & Simon, G. (2018). Mining electronic health records (EHRs) A survey. ACM Computing Surveys (CSUR), 50(6), 1-40.