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The evolution of nursing informatics
The evolution of nursing informatics
Institute of medicine addressing nursing informatics
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Introduction This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional. Annotated Bibliography Englebright, J., Aldrich, K., & Taylor, C., (2014) Defining and Incorporating Basic Nursing Care Actions Into the Electronic Health Record. Journal of Nursing Scholarship. 2014; 46:1, 50-57 The authors consist of nurses, specifically: a Chief Nursing Officer, a Nursing Informatics Officer, and a Dean/Professor of Nursing at Belmont University. The article described how vital nursing documentation is to achieve optimal patient care, including improving patient outcomes & collaborating with other healthcare providers. Using Henderson’s 14 fundamental needs as a framework for their research, the authors proved a definition of basic nursing care and incorporated it into an electronic health record. The authors utilized a team of 16 direct care nurses who were knowledgeable with documenting ele... ... middle of paper ... ...., & Ross, D. A. (2013). Electronic Health Records and US Public Health: Current Realities and Future Promise. American Journal Of Public Health. 103(9), 1560-1567. Halley, E., Sensei, J., & Brocken J. (2009). Nurses Exchanging Information: Understanding Electronic Health Record Standards and Interoperability. Urologic Nursing. September 2009; 29(5): 305-313 Murphy, J., (2010). The Journey to Meaningful Use of Electronic Health Records. Nursing Economic$. July-August 2010; 28(4) 283-287 Murphy, J., (2011). The Nursing Informatics Workforce: Who Are They and What Do They Do? Nursing Economics, 29(3), 150-3. Retrieved from http://search.proquest.com/docview/871355814?accountid=400921 Stonham, G., Heyes, B., Owen, A., & Povey, E., (2012). Measuring the nursing contribution using electronic records. Nursing Management. December 2012; 19(8)28-32
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
Jha, A. K., Burke, M. F., DesRoches, C., Joshi M. S., Kralovec P. D., Campbell E. G., & Buntin M. B. (2011). Progress Toward Meaningful Use: Hospitals’ Adoption of Electronic Health Records. The American Journal of Managed Care, 17, 117-123
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Many new technologies are being used in health organizations across the nations, which are being utilized to help improve the quality of health care. Electronic Health Records (EHRs) play a critical role in improving access, quality and efficiency of healthcare ("Electronic health records," 2014). In order to assist in expanding the use of EHR’s, in 2011 The Centers for Medicaid and Medicare Services (CMS), instituted a EHR incentive program called the Meaningful use Program. This program was instituted to encourage and expand the use of the HER, by providing health professional and health organizations yearly incentive payments when they demonstrate meaningful use of the EHR ("Medicare and medicaid," 2014). The Meaningful use program will be explored including its’ implications for nurses, nursing, national policy, how the population health data relates to Meaningful use data collection in various stages and finally recommendations for beneficial improvement for patient outcomes and population health and more.
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an incentive, the government began issuing payments to those providers who “meaningfully use certified electronic health record (EHR) technology.” (hhs.gov) There are three stages that providers must progress through in order to receive theses financial incentives. Stage one is the initial stage and is met with the creation and implementation of the HER in the business. Stage two “increases health information exchange between providers.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) Stage three will be the continuation and expansion of the “meaningful use objectives.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) The hospital, where I work, initiated the HER mandate many years ago. In this paper, I will discuss the progression and the challenges that my hospital encountered while implementing the EHR mandate.
In this paper you will find that the transition from paper health records to electronic medical record is a transition that requires a lot of time and precise preparation and planning. Looking through the paper you will see that there are factors that need to be implemented. You first definitely have to have your medical records. Next you have to know the role that HIPPA will play in your transition because of regulation and violations. Then, you have to prepare for potential problems that you could possibly face. Next, you will see there are several things to evaluate from how long it will take to cost. You will see prices for workstation and the number of staff that you need to carry out your plan of action.
Nursing documentation is an important factor of healthcare delivery today. The use of information and communication technology offers opportunities for improving patient care delivery while reducing nurses’ documentation load and increasing the time available for caring for various patient populations (Munyisia, Yu, & Hailey, 2012).
The Health Information Technology for Economic and Clinical Health (HITECH Act), which was passed as part of the American Recovery and Reinvestment Act of 2009, has fostered significant progress in the adoption of Electronic Health Records (EHRs) in various clinical settings, particularly through the Medicare and Medicaid EHR Incentive Programs and its focus on EHR adoption in Stage 1 Meaningful Use (CITATION gov). For instance, as a result of the Medicare and Medicaid EHR Incentive Programs, the percentage of office based physicians who have adopted an EHR system dramatically rose from 18.2% in 2001 to a staggering 78.4% in 2013 (CITATION phys data). Additionally, as of July 2013, 67% of hospitals achieved Stage 1 Meaningful Use and an additional 16% were paid for adopting EHRs (CITATION hosp data).
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
Technology has tremendously impacted the world and has brought about many changes, especially to those in the medical field. Prior to having such an advanced technological based society, medical charts were all on paper. With the advancement of technology, Electronic Health Records were created. According to the Healthcare Information and Management Systems Society(HIMSS, 2012-2014), the Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The Electronic Health Record has the potential to change the health care world. This system allows members of the medical team to have information related to their various patients at the level of their convenience. There are many advantages and disadvantages to the EHR and all of these risks and benefits are taken into consideration when establishing its use. It is vital to understand the advantages and disadvantages of the EHR in order to determine if the benefits of the system outweigh the risks.
The process of implementing an EHR occurs over a number of years. An electronic record of health-related information on individuals conforming to interoperability standards can be created, managed and consulted with the authorized health professionals (Wager et al., 2009). This information technology system electronically gathers and stores patient data, and supplies that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system functions as a decision support tool to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lower the medical costs. Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely to provide better preventive care than were healthcare professionals who did not.
NURSING INFORMATICS Need Assessment Electronic Health Records (EHR) is considered a new standard for medicine performance. According to world health organization, the electronic health record is the most resource intensive and complex activity in any medical practice (WHO, 2006). Despite advancement in technology, preparation and needs assessment, EHR can be successfully implemented. Need assessment could provide relevant feedback to upper management in correct decision making, thus identifying the requirement and areas that are essential for the wellbeing of hospitals and patients (Ash, 2004). Implementing Electronic health records will solve many ongoing problems, but whether the EHR successfully meets the expectations depends upon how complex
The article presents the importance and implementation of nursing documentation and discusses the application of electronic documentation systems. Nurses’ documentation serves many purposes. It is essential in monitoring patient outcomes, is important for the quality improvement process, and can make a difference in who pays for medical care. Alkouri, AlKhatib, and Kawafhah (2016), state that documentation includes important aspects such as a legal evidence of care, provides a way to assess efficiency of care, provides data and evidence for research, can be used for financial quality assurance purposes, provides a database to support nursing knowledge, and helps improve nursing education and clinical
Ragavan, V. (2012, August 27). Medical Records Pals Malaysia : 17 Posibble Reasons How Electronic Medical Records (EMR) Might Support Day-to-Day Patient Care. Retrieved from Medical Records Pals Malaysia: http://mrpalsmy.wordpress.com/category/emr/