Applications of EHR on Inpatient Nursing - Essay Example

?Application of EHR on inpatient nursing Introduction Organizational efficiency is one of the major beneficiaries of technological developments. Advancements in information technology have for example been used in monitoring and evaluation of operations besides facilitating communication. Electronic health record, a system electronic based record keeping in health care institutions, is an example of application of information technology developments that has been incorporated in the health sector to facilitate communication and management of information for operational efficiencies. This paper seeks to discuss application of electronic health record system in inpatient nursing. The paper will explore application of the technology in inpatient nursing’s assessment, medication, and documentation. It will also explore successful implementation of the electronic health record system and its importance in the scope of inpatient nursing. Application of electronic health record in documentation The core function of electronic health record is the development of a reliable information system for efficiency. This has led to transition, alongside technological developments, from a manual record keeping system to the electronic system through computer technology. The information system has further enhanced the health record system through networking involved instruments, departments, and personnel in the electronics record systems. Documentation is, as a result, one of the applications of electronic health record system through a variety of system applications that includes provision of information in facilities such as inpatient nursing facilities. The scope of documentation, based on its definition, includes recording of information and availing the recorded information for necessary use. The “nursing information system,” an incorporated system in inpatient nursing institutions is for example used in documenting information for administrative purposes (Carter, 2008, p. 4). The system manages all information relating to inpatients such as patient’s admission that provides relevant details of a patient to the hospitals system (Carter, 2008). Guite et al further explains that electronic health record is used to capture and communicate a patient’s details for determination of patients’ needs and evaluation of the patients’ utility while in the nursing facilities. Coordination also facilitates knowledge of patients’ needs among personnel on duty (n.d.). Documentation in electronic health record is also used to facilitate management of information for timely discharge of patients and even transfer of patients to other facilities for specialized attention. Like in admission, documentation, through a centralized operated system facilitates inter departmental communication to relay the need for either discharge or transfer. Similarly, documentation as an element of electronic health record facilitates accounting aspects of health care institutions, a role that is achieved through recording and organization of financial transactions and communication of the information to managers for administration (Carter, 2008). Inpatient nursing facilities also use electronic health record’s documentation to facilitate direct personal communication among nurses through online chats for instant communication. The application of electronic health record in documentation is therefore based on its ability to develop a bank of necessary and relevant information to inpatient care and to communicate such information to relevant departments and personnel for efficient operations and management. Standardized terms and systems for uniformity in documentation facilitate the efficiency by eliminating language based communication barrier (Carter, 2008). Application of electronic health record in nursing’s documentation is however subject to legal considerations that aim at preventing malpractices such as fraud. Such rules apply to both EHR technology developers and users in inpatient nursing facilities (Ahima, 2007). Application of electronic health record in medication Electronic health record system is similarly applied in inpatient nursing care’s medication. Medication refers to administration of treatment through drugs and largely relies on record keeping systems for efficiency through developing a link between different involved departments and personnel. The scope of medication therefore identifies the application of electronic health record’s communication features in meeting inpatients needs through the technology’s ability to link a series of steps, and their associated departments, in the entire process that leads to medication. Once the system has communicated admission of patients, diagnosis is done and prescriptions relayed for administration of drugs. Similarly, the system keeps records of a patient’s treatment for monitoring progress and ensuring provision of appropriate medicines. EHR system’s efficiency with respect to speed of data retrieval also means that an ineffective drug or one that adversely affects a patient can immediately and appropriately be substituted after a quick review of the patient’s details and active ingredients of the subject drug (Carter, 2008). Another medication application of electronic health records that closely relates to record keeping and communication is reconciliation of a patient’s medication. Reconciliation however goes beyond review of a patient’s previous medication and attempts to enhance accuracy in medication. This application of the record system helps in minimizing and possibly mitigating “errors such as omissions, duplications, dosing errors, or drug interactions” (Indian, n.d., p. 1). Medication reconciliation is particularly necessary in case of changes in nursing personnel, environment, and type of care, medicines, or reissue of drugs. In such cases, the electronic system helps in reviewing the drugs that are currently used by a patient, the newly prescribed drugs, and compares the two sets of medication. The same procedure applies to other changes and is facilitated by the system’s readily available information, followed by an informed decision on a patient’s appropriate medications and care. The EHR’s application in medication therefore facilitates termination of ineffective medications to a patient or those drugs that adversely affect the patient, and development of a set of appropriate medication (Indian, n.d.). A research that was conducted by Linder et al in 2010 over the effectiveness of electronic health record system in identifying and communicating adverse effects of medication supports the system’s effective role in drug reconciliation. According to the authors, the system improves efficiency in identification of inappropriate drugs and is widely acceptable to nurses for application in healthcare facilities, including inpatient nursing care facilities (Linder et al., 2010). Further, as identified by Hammaker and Tomlinson, the electronic health record system facilitates response to changed prescriptions in a patient’s medication, an application that majorly relies on the system’s role in facilitating communication and effecting medication changes immediately recommendation are made by the reconciliation team. The system, through “computerized decision support” also facilitates general review of drugs to ensure safety of inpatients as the support system identifies risky recommendations from reconciliation phase (Hammaker and Tomlinson, 2010, p. 367). Application of electronic health record in inpatient nursing assessment Electronic health record system is also applicable in nursing assessment in different scopes. As witnessed in ‘evidence-based’ practice, electronic health record system facilitates review of nursing practices for assessment with the aim of determining the possibility of success or effectiveness of a nursing practice. Based on its efficient ability to readily avail data and information, electronic health record system is used as an instrument for assesing literature on practices. The system’s database provides a bank of literature on patients’ cases that can be retrieved, reviewed, and compared with a current patient’s case, to determine the most suitable nursing practice for adoption. This identifies application of electronic health record system to assess nursing initiatives for efficient care (McGonigle and Mastrian, 2011). The system also has automatic assessment programs for monitoring nursing activities in inpatient care, detecting anomalies, and creating notifications. The “computerized physician order entry” is an example of automatic assessment programs (Mastrian, 2011, p. 231). This application assesses prescriptions for patients and based on a patient’s fed in details, into the system, rejects an inconsistent prescription. The record system also aids assessment of inpatient nursing care through its ability to “reporting functions” (Mastrian, 2011, p. 231). Its scope that facilitates administration through linking departments also implies its application in central assessment of nursing practices in a nursing clinic. This is because it allows for the administration’s access to all information on nursing processes from a central place for reviewing and development of corrective measures. Similarly, the system’s ability to relay delays in medication as well as assigned personnel facilitates a centralized assessment of activities by administration. The administrative assessment also includes evaluation of applied methods by nurses to determine whether they are appropriate and effective to inpatients’ needs (Mastrian, 2011). Safeguarding patients’ confidential information Even though the electronic health record system facilitates access to patients’ information through interconnected networks, the system has measures, based on legal and ethical requirements, to ensure that patient’s privacy is safeguarded. Legal provisions for example recognize a patient’s privacy that must be respected by inpatient nursing personnel. While the general legal privacy requirements calls for total non disclosure of a patient’s personal information to any third party, without the patient’s consent, the electronic health record system that links many care providers and avails patients’ information to the network, seems to contravene the total privacy policy. The Health Insurance Portability and Accountability act, United States legislation, is one of the legal measures that ensure safety of patient’s confidential information in electronic health record system. An inpatient nursing facility for example has a legal obligation to guarantee confidentiality of patients’ information, an indication that a well established EHR system safeguards patients’ details from “invasion, accidental disclosure, or loss” (Blesi, Wise and Arney, 2011, p. 234). Under regulations that communicates restriction in availability of patients’ information to controllable networks, nursing care providers must prove their capacity to maintain “confidentiality, integrity, and availability of electronically protected health information” in their electronic systems (Blesi, Wise and Arney, 2011, p. 235). Similarly, every organization is required to develop policies and procedures that deter its employees from illegally disclosing a patient’s information. Every organization must also ensure that the confidential information is protected from any external threats such as hackers. In order to achieve the objectives of the rules, only specific personnel who satisfy criterion for licensing to operate the electronic health record can access patients’ information in the system. This means that the electronic health record system, as applied in inpatient nursing facilities, safeguards patients’ confidential information (Blesi, Wise and Arney, 2011). Benefits of electronic health record in inpatient care The wide scope of application of electronic health record system yields a number of advantages to both nursing facilities and the inpatients. One of such benefits is higher efficiency with respect to implementing relayed instructions, a consequence of the improved communication between departments and personnel that relays timely and clear sets of instructions. The system also promotes general efficiency in nursing practices through its assessment scope that identifies possible errors for corrective measures besides its data bank (Carter, 2008; McGonigle and Mastrian, 2011). Conclusion Electronic health record system, a development from the traditional manual system of record keeping, facilitates efficiencies in inpatient nursing facilities. Such efficiencies are realized in documentation, medication, and assessment of care procedures. Though the system appears to be vulnerable to confidentiality breach, it is regulated by both legal and ethical requirements that help personnel to safeguards patient’s confidentiality. References Ahima. (2007). Guidelines for HER documentation to prevent fraud. Retrieved from: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_033097.hcsp?dDocName=bok1_033097 Blesi, M., Wise, B. and Arney, C. (2011). Medical Assisting Administrative and Clinical Competencies. New York, NY: Cengage Learning Carter, J. (2008). Electronic Health Records: A Guide for Clinicians and Administrators. Philadelphia, PA: ACP Press Guite, J., Lang, M., McCartan, P. and Miller, J. (n.d.). Nursing admission process redesigned to leverage HER. Journal of Healthcare Information Management. (20.2) 55-64. Hammaker, D. and Tomlinson, S. (2010). Health Care Management and the Law: Principles and Applications. New York, NY: Cengage Learning Indian. (n.d.). Electronic health record (EHR). Retrieved from: http://www.ihs.gov/cio/ehr/index.cfm?module=medication_reconciliation Linder, J., Iyer, A., Labuzetta, M., Ibara, M., Celeste, M., Getty, G. and Bates, D. (2010). Secondary use of electronic health record data: spontaneous triggered adverse drug event. Pharmacoepidemiology and Drug Safety. (19) 1211- 1215 Mastrian, K. (2011). Integrating Technology in Nursing Education: Tools for the Knowledge Era. Sudbury, MA: Jones & Bartlett Publishers McGonigle, D. and Mastrian, K. (2011). Nursing Informatics and the Foundation of Knowledge. Burlington, MA: Jones & Bartlett Publishers Read More