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 EMR effects on patient care 

The health care field is always evolving to achieve quality care and better patient outcomes. Today, there are numerous investigative and treatment options to facilitate better patient care. Health professionals are more equipped in patient assessment for comprehensive care. Largely attributable to the historical milestone is the focus on good sources of information and multidisciplinary collaboration. Electronic medical records (EMR) and all related information technology are now part of influencing quality patient care and outcomes. Many physicians and other health professionals have adopted them as part of quality improvement measures in modern practice. Understanding more about EMR’s can help unveil the nursing implications to quality care and better patient outcomes compared to the traditional paper-based system.

EMR’s and Access to Information

EMR’s enhances care coordination between one provider and another. They provide health professionals with patient information in a manner that surpasses the efficiency of traditional paper records. It is now easy to access a patient’s diagnosis, allergies, laboratory results, and medications with ease at the point of care (Manca, 2015). The arrangement reduces care fragmentation by allowing the integration, organization, and distribution of a patient’s health care information to all authorized care professionals. It also promotes access to accurate and updated information about a patient from one health professional to another (Manca, 2015). Consequently, this information ensures that they have all the necessary data to make comprehensive care plans.

EMR data can be a good source of data to inform practice and research. By ensuring proper use and consistent data entry, EMR’s provide nurses with valuable information about the nature of their practice, quality of care, and gaps in practice (Manca, 2015). It then becomes a good source of practice-level interventions towards better outcomes. A good example is using EMR data to identify the number of women who receive mammograms within a specific period. Such information can help reveal the quality of care by identifying the screening rates or the set target achievements. It is proof of EMR data in informing practice towards better patient care.

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Impact on Workflow

The use of EMR's s is effective in reducing medication errors. The errors have been a persistent threat to quality care with negative patient and nurse outcomes. However, the introduction of electronic medical records has provided the required hope to reduce occurrences (Manca, 2015). The systems provide a safety component to the medication process through safety alerts in the medication prescription and administration stages. It eliminates the mistakes that often occur in traditional prescribing practices of illegible handwriting, wrong dose, incorrect route, history of allergies, and incomplete information about medication allergies (Vaidotas et al., 2019). Through warnings in the EMR's, nurses can identify errors in the medication process and take action to avert any impending medication error. Such benefits continue to emphasize the historical strides towards achieving quality health care.   

Also, EMR's alert or remind health providers about guidelines in the prevention and treatment of conditions and diseases for their patients. For example, a study by Konerman et al. (2017) states that EMR's can help screen and treat patients for Hepatitis B. Through alerts, researchers from the University of Michigan succeeded in urging patients to take HCV screening and initiate evidence-based measures towards treatment. In the same approach, DeSalvo et al. (2018) prove that EMR’s are effective in increasing health professional’s adherence to the youth diabetic screening guideline from the American Diabetes Association. Such measures facilitate best practices towards quality care and better patient outcomes.

Patient Safety

EMR’s promote a patient’s civil right to privacy and security of data. Under HIPAA, there are strict guidelines to protect a patient’s data during creation, storage, and transmission. The purpose of such strict stipulations is to improve efficiency in health care by ensuring the security of patients' information. Through EMR’s, nurses can protect a patient's data through firewalls, cryptography, antivirus software, and cloud computing to ensure that data is not accessible to any unauthorized persons (Kruse et al., 2017). Adherence promotes the patients' rights, upholds nurse-patient confidentiality, and limits unnecessary disciplinary action for violations. Alternatively, the same cannot be said in traditional paper-based systems where patient information may be easily accessible to third parties. It is also easy to alter or replace information on paper in an undetectable manner, a significant flaw and violation of a patients’ rights. Such limitations in traditional paper-based systems cannot over-emphasize the benefit of EMR’s in improving patient safety.

Improved Communication

Effective communication is one of the basic tenets of quality health care. It facilitates patient safety, reduced costs, and the overall well-being of a patient in the health care setting. EMR’s have been a major component of establishing effective communication in patient care through clear, legible, and structured information (Singer & Fernandez, 2015). It enables nurses to spend less time making clarifications from the pharmacy, physicians, and other health professionals.  Such improved interactions create enough time for nurses to provide quality and appropriate care to patients (Singer & Fernandez, 2015). It is a highlight of the role of EMR’s in establishing effective communication among health professionals towards better care.

Impact of EMR’s on Documentation

Nursing documentation is part of the care process for good clinical communication. Accurate documentation is a reflection of nursing assessment, change in patient condition, specific care approaches, and any necessary information to guide the care plan (Akhu-Zaheya et al., 2018). Although it is part of patient care, spending too much time in documentation compared to time spent in patient care may hinder quality care delivery. The traditional paper-based documentation is hugely responsible for creating such time disparities in nursing care (Akhu-Zaheya et al., 2018). It reduces nurse satisfaction and limits time for any patient-centered interventions. In contrast, EMR’s have shown superiority to paper-based systems in process and structure. Evidence reveals that bedside EMR terminals can reduce documentation time up to 24% and increase the amount of time available for the nurse to engage in other goal-directed approaches to patient care (Akhu-Zaheya et al., 2018). It is proof of the role of EMR’s in facilitating nurses towards quality care.

Conclusion

The impact of EMR’s on nursing and patient care cannot be over-emphasized. It is a significant development from the traditional paper-based system. Nurses now have an efficient approach to accessing patient data, improving communication, and can spend less time in documentation. Moreover, they can protect patient data in compliance with HIPAA and avoid litigation. Consequently, patients can benefit through reduced medical errors, increased quality of care, and better outcomes. Based on these achievements, it is possible to see a future that embraces EMR’s as prerequisites for success in health care delivery.

 

 

References

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. DOI: 10.1111/join.14097

DeSalvo, D., Bartz, S. K., Mockler, B., & Sonabend, R. Y. (2018). Use of Best Practice Alerts to Improve Adherence to Evidence-Based Screening in Pediatric Diabetes Care. Journal of Nursing & Interprofessional Leadership in Quality & Safety, 2(1), 7.

Konerman, M. A., Thomson, M., Gray, K., Moore, M., Choxi, H., Seif, E., & Lok, A. S. (2017). Impact of an electronic health record alert in primary care on increasing hepatitis c screening and curative treatment for baby boomers. Hepatology, 66(6), 1805-1813.

Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017). Security techniques for electronic health records. Journal of medical systems, 41(8), 1-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522514/

Manca, D. P. (2015). Do electronic medical records improve the quality of care? Yes. Canadian Family Physician, 61(10), 846. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607324/

Singer, A., & Fernandez, R. D. (2015). The effect of electronic medical record system use on communication between pharmacists and prescribers. BMC Family Practice, 16(1), 1-6. https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0378-7

Vaidotas, M., Yokota, P. K. O., Negrini, N. M. M., Leiderman, D. B. D., Souza, V. P. D., Santos, O. F. P. D., & Wolosker, N. (2019). Medication errors in emergency departments: is electronic medical records an effective barrier? Einstein (São Paulo), 17(4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611086/

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