Electronic Medical Records Essay
Electronic Medical Records
Electronic Medical Records (EMR) are becoming more widely used across the healthcare spectrum. One of the reasons for their popularity is the potential that is presented for increasing the quality of care delivered to patients by decreasing handwriting interpretation errors, reducing medication administration errors and eliminating lost charts. Time management is a crucial skill to have as a nurse. It allows for a smooth workflow which translates into quality patient care. Much time can be wasted not only by the nurse signing off illegible handwritten orders, but also by the other nurses that have to help interpret the handwriting.
The EMR requires the physician to enter orders electronically, thereby eliminating handwritten orders. Electronic orders are more precise and more accurately followed (Sokol, 2006). Fewer errors make it to the patient, reducing unnecessary tests and increasing the quality of care that patients are receiving. Electronic medication administration records (MAR) are useful in displaying medications due at specific times. Not only is it possible to sort the medications due at one time, the MAR will also alert the nurse to potential drug interactions. Late medications will be displayed in red to be easily seen.
If bar coding is implemented, medication errors can be reduced by a range of 60%-97% (Hunter, 2011). A lost chart can be very frustrating while trying to deliver seamless care to a patient. Paper charts are easily misplaced. Since there is only one, if a single provider is using it, no one else of the medical team can view the chart. The EMR can be viewed from any computer with secure internet access or on a handheld device. When the internet is down, a downtime view only access is available. Nursing Involvement Nurses are known as patient advocates.
In advocating for their patients, nurses strive for what is best in their patient’s care. Since nurses will be using the EMR most frequently, it is imperative that they are part of the selection and implementation on an EMR. A nurse, on the EMR team, will represent all nursing. Nurses will be accessing the EMR through their shift several times and will become familiar with the layout and workflow and will be able to provide insight into what would work best to ensure quality of care. There is a saying that you don’t know what you don’t know. A nurse knows what she will need and is the best to supply this information.
While researching which EMR would be the best for a facility, a nurse can provide information on time saving workflows between systems. Nurses must also be trained as super users to provide a seamless change from paper charting to electronic charting and provide support to fellow nursing staff. A nurse on the EMR team will be able to deliver new information in a way that other nurses are more receptive to. Handheld Devices If nurses were to use handheld devices in delivery of patient care, there would be a noticeable savings of time as well as more accurate charting.
Nursing personnel carrying a handheld device would have immediate access to their patients chart to notice new orders, lab results, or medication admission records. The need to review the paper chart repeatedly throughout the day would be eliminated along with the long search that commences every time you have to look for the paper chart. This could add several minutes to a nurse’s time at the bedside, improving patient satisfaction. When vital signs are taken, written on a slip of paper and then transcribed into the paper chart, there are many opportunities for error and delay.
Numbers can be transposed, written incorrectly or the wrong patient’s information could go into a chart. With the immediate availability of a handheld device, the information from the vital signs monitor would have the ability to interface into the patient’s chart virtually eliminating late charting and errors. Security Standards The Health Insurance Portability and Accountability Act (HIPAA) was initiated in 1996 as a standard for protecting individually identifiable health information (U. S. Department of Health and Human Services).
HIPAA requires that all information, either written or electronically, that falls under the criteria is protected from unauthorized viewers. An EMR carries more stringent HIPAA guidelines than a paper chart due to the risks associated with computer based files and there are a few key steps that must be taken to ensure compliance with this act. Access control: each user will have a unique user name and password that must not be shared. Firewall protection must be used on the internet server the hospital utilizes to prevent hackers from obtaining access to protected information.
If users are authorized to access patient information from home, there must be a secure server used (Arevalo, 2007). Storage: Data must be encrypted to enhance the security while information is being stored and while it is transferred. Encryption entails protection of files and data that is only viewable to authorized users. Compliance of these regulations should be audited on a regular basis with any violation being swiftly remedied (Medical Records, 2013). Healthcare Costs Purchasing an EMR can cost hundreds of thousands of dollars.
In order to justify such a large purchase, one must examine the potential ways that money can be saved while using an EMR. After spending hours training users and with a little practice, nurse’s workflows will improve and less time will be wasted. A chart will not have to be searched for, double or triple charting is eliminated by using handheld devices for immediate charting. The quality assurance team will be able to run reports on compliance of core measures and be able to recommend changes to nursing personnel to implement. Fewer medication errors will be made by using the electronic MAR.
Most importantly, these time and money saving factors will enhance patient safety. With fewer paper charts to store, valuable space can be remodeled into patient care areas that offer services not previously offered due to space issues (Power, 2013). This will increase revenue for the facility. Comparison Epic offers a computerized management system that is utilized by everyone in the healthcare setting including, nurses, nurse aids, physicians, dietary, radiology, emergency department and the business office. Each department will have a unique look and functionality to their program.
There is no need to use multiple systems to gather information on a patient. It can be used in medium size ambulatory settings such as a clinic as well as in a hospital setting for either inpatients or outpatients. With all departments having access to the same information on a patient, errors will be reduced in delivery of patient care. The chance for entering erroneous lab results or miss- documentation will also be reduced with department specific workflows. Not only will this result in better patient care, but also in a nurse’s ability to delivery effective, efficient, quality care without delay.
In addition, all physician order entry is electronic, every time. Order sets can be customized for each prescriber, saving time and hassle while maintaining meaningful use and following core measures. For added security, the system can be set to automatically sign a user out after a specified length of time of non-use. And while all of the patient’s information is available to each user, audit trails are left enhancing patient security. Epic has pre-loaded patient teaching materials available as well as the option to custom make information.
After visit summaries are easily printed upon discharge and an electronic copy is permanently attached to the chart. Patient would benefit from a facility the uses the Epic system by having access to MyChart. MyChart is a portal of access between a patient and their provider for communication as well as a portable computerized health record. IF a patient were to access care from a facility that does not utilize the Epic system, that patient would have access to MyChart and would then be able to provide critical information that would enhance their care. Another computerized management system available is one from Cerner.
This system can be used in all settings in a hospital including nursing. For medication administration, Cerner has available barcode identification of medication to help nursing staff complete their five rights verification prior to administration. It also allows charting at the bedside to enhance accuracy either through a handheld device or a stationary computer. All order entry by physicians is done on the computer allowing the providers to follow built in prompts for allergy information and adverse drug interactions as well as prompts that will aid in the order of care protocols to enhance patient care.
Cerner also has a portal designed for patient to have access to their records no matter where they are as well as tracking information for health goals a patient and their provider have established. The portal allows progress tracking and provides information on steps that can be used to help the patient reach their goals. This gives patients more responsibility for their health while providing the incentive needed. Nursing care will be escalated similarly to the way it would be in Epic.
Patient information is easily accessible through intuitive workflows allowing nursing staff to make responsible decisions regarding patient care. My recommendation for a computerized management system would be the one available from Cerner. It is the most user friendly for staff including nursing and offers intensive training and yearly upgrades. The different departments systems appear to work together seamlessly resulting in increased savings of time and money (Cerner, 2013).