Paper Example on Electronics Health Records (EHR)

Introduction

The Health information technology (HIT) such as Electronic health records (EHRs) system promise to improve effectiveness and efficiency in the delivery process of health care, to improve quality care and to reduce health care related costs. National Coordinator for Health Information Technology (ONCHIT) main objective is to implement EHRs nationwide. EHR is a patient oriented intelligent system, which compiles the medical records and data of patients to support ultimate decisions and core processes. In a health care setting, EHR is expected to help in making clinical decisions and care process while at the same time capturing, storing and recovering patient digital data in the required format. Just like information systems, EHR systems increase strategic roles in a health care system with the aim of offering quality care. However, just like any information system, EHR has many important barriers such as its contribution to medical errors. To support health care organizations, EHR systems should be used in multiple patient care departments and processes to help heath care practitioners with their jobs. However, nurses may have different objectives and expectations from the use of HER system to support their decision making and support their information needs. Therefore, HER systems can transform the health care system from a paper based firm to a digitalized firm that used patient's information to deliver high quality patient care.

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Why we Need EHRs

The electronic information systems have unlocked diverse possibilities and replaced paper based health care data management system that is important in providing quality care and during clinical research. Many studies have shed light on qualities (currency, plausibility, concordance, correctness, and completeness) of data contained in EHRs. EHRs as a electronic record contains data and patient's health information such as patient's past medical history, laboratory data, vital, signs, immunizations, medications, problems, progress notes, and radiology reports. HER systems have many capabilities of reducing costs and improving patient's care such as health information exchange (HIE), computerized physician order entry (CPOE) systems, and clinical decision support (CDS) tools.

The clinical decision support (CDS) tools helps in the decision making process during patient care including alerts for drug interactions, cross-referencing a patient allergy, and other potential patient issues. This functionality ensures care is delivered in a more efficient and safer manner. The CPOE systems allow nurses to key in laboratory tests, physical therapy, radiology and drug tests. Such of computerization process reduces chances of dangerous medical errors. It also makes the process of ordering more effective since pharmacy and nursing staffs do not have to solicit missing information and need to seek clarification from incomplete or illegible orders. Once patient's data and information is available electronically, information is shared securely and it reduces costly redundant tests. This means that EHR not only provides quality care, but also provide efficient, effective and quality care. The quality of documentation is not only important to patient care but also to the organization's financial status. Such systems offer the potential of enhancing efficiency, quality and safety during the provision of health care. Thus, the use of EHRs presents major opportunities that improve patient outcome.

EHR Value and Benefits

EHR has many potential benefits compared to paper based record keeping systems. The main benefits of EHR ranges from financial savings to health benefits most of which result from efficiencies when using EHR systems. Some direct benefits of EHR include better collaboration and communication, legibility, accuracy, completeness and consistency. For these benefits to arise, EHR must be easily available, accessible, flexible and user friendly.

Most clinical outcomes that have been linked to EHR are lined to patient safety and quality of care. Quality care results from doing the right thing the right way at the right time, which leads to patient safety and best results. Therefore, EHR focuses on efficiency, effectiveness and safety of patients. HER with CDC tools are believed to increase patient's adherence to effective care and evidence based clinical guidelines. HER try to overcome issues such as nurses not knowing the guidelines, lack of time during the patient visit, and nurses not realizing the kind of guideline that is applicable to a particular patient. Instead EHRs focus on preventive services such as how to improve the rate of adherence among patients.

EHRs also allow nurses to access easily patient's clinical information during care. For example, there are Cusack (2008) in her study shows that sub specialty referrals that needs interactive communication and coordination among nurses have been facilitated using HER in the US. According to Creswell eat al. (2012), the EHRs can also be used to communicate with patients over long distances. Besides, Robert (2010) in his study found that the use of EHRs improves accuracy and completeness of records. Further research also shows that EHRs is one of the major areas used in aged care to deliver safe and effective quality aged care. Thus, EHRs is important in a health care environment to provide improved care and information quality based on accuracy, completeness and legibility.

Rationale

Care delivery in nursing involves conflicting view points among health care practitioners. Electronics Health Records (EHR) involves a systematic investigation aimed to produce the best evidence when providing quality care for patients. For example, Post Traumatic Disorder is a common psychiatric problem among individuals in the military service. Nurses can use psychotherapies such as cognitive processing therapy (CPT) while caring for such patients.

In the community-based clinic where I am working, both individual and group therapies are provided by team psychologists. CPT as a medical therapy has increasingly delivered a positive response. The rationale of HER has proved to be effective because patients are treated with respect and informed on the importance of strict adherence to treatment.

The goal for treating PTSD can be undermined through the failure to document treatment outcomes for patients. Nurses should realize that familiarity with patient's culture, believes and perception may affect the direction of treatment. Through documentation of treatment outcomes, they will be able to measure the effectiveness of CPT treatment and how it can increase CPT adherence and utilization. Thus, observance of policy and documentation form initial to final assessment can support the adoption of CPT as an EBP practice.

The major barriers to implementation of EBP include patient limitations such as cognitive limitations and lack of motivation, while clinical limitations include biases, lack of training, lack of resources and physical exhaustion to help in adoption of EBP. These barriers can be overcomed through collaborative efforts such as sharing information, assisting and discussing. New techniques can also be adapted to provide the best treatment such as creating a conducive environment where peer to peer information and knowledge sharing are promoted. These barriers can be overcomed through collaborative efforts such as sharing information, assisting and discussing. New techniques can also be adapted to provide the best treatment such as creating a good environment where peer to peer information and knowledge sharing are promoted. Through documentation of treatment outcomes, they will be able to measure the effectiveness of CPT treatment and how it can increase CPT adherence and utilization. Thus, observance of policy and documentation form initial to final assessment can support the adoption of CPT as an EBP practice.

Training nurses will also ensure confidence and literacy skills to deal with mental, physical and emotional problems among patients with PTSD.

The following precautions should be taken. First, the patient should commit to maintaining the recommended blood glucose levels. This will require that Ms. G sticks to a healthy lifestyle with regards to diet and exercise. Not only will this lower her body mass index to a healthy level, but it will also decrease the risk for cardiovascular diseases. A balanced diet is mandatory in boosting her immune system. Not only will this lower her body mass index to a healthy level, but it will also decrease the risk for cardiovascular diseases. A balanced diet is mandatory in boosting her immune system. Vitamins are essential in manufacturing new white blood cells thereby increasing the body's defense against infections. Other foods such as pro-biotics and catechins have been shown to boost the immune system generally. Ms. G must also practice proper diabetics wound care to facilitate the healing. The appropriate dressing should be used on the wound to speed up the healing process. She should frequently check for possible wounds and signs of developing infections to enable rapid therapeutic response and minimize complications.

References

Linder, J. A., Ma, J., Bates, D. W., Middleton, B., & Stafford, R. S. (2007). Electronic health record use and the quality of ambulatory care in the United States. Archives of internal medicine, 167(13), 1400-1405.

Tang, P.C., Ralston, M., Arrigotti, M.F., Qureshi, L. and Graham, J., (2007). Comparison of methodologies for calculating quality measures based on administrative data versus clinical data from an electronic health record system: implications for performance measures. Journal of the American Medical Informatics Association, 14(1), pp.10-15.

Pizziferri, L., Kittler, A. F., Volk, L. A., Honour, M. M., Gupta, S., Wang, S., ... & Bates, D. W. (2005).

Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study. Journal of biomedical informatics, 38(3), 176-188.

Weiskopf, N. G., & Weng, C. (2013). Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research. Journal of the American Medical Informatics Association, 20(1), 144-151.