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THE ELECTRONIC HEALTH RECORD SYSTEM

BY MR. ADEDE KEVIN.J,RN

OPERATING ROOM NURSE

©2023

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DEFINATION

Electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings.

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EHR VS EMR

Electronic medical records (EMRs) are digital patient records and charts while electronic health records (EHRs) include this information and more.

EHRs include tools for All Aspects of documentation from aspects of medical and nursing and allied health care delivery including prescribing medications electronically, ordering labs, streamlining internal and external communications and sharing data.

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NURSING PRACTICE BEFORE EHR

  • Documentation was done on paper & physical charts.
  • Physical charts and patient files would then be stored at the Health record department’s cabinets.
  • Laboratory requests forms were collected by RNs to consultants to be filled for specimen processing.

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ADVANTAGES OF PAPER HEALTH RECORDS

  • No password needed for any documentation to be done.
  • Easy to make correction incase of wrong entries
  • Economical to facilities
  • Easily accessible i.e. printing & photocopying
  • Tracking of changes were not time stampeded

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CHALLENGES OF PAPER HEALTH RECORDING

  • Loss of data incase of physical damage such as fire or water.
  • Confidentiality can be compromised if documents land on unauthorized personnel.
  • Tempering with documentation is easy.
  • Illegibility hence difficult to read hence hindrance to communication e.g. prescriptions

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CHALLENGES BEFORE EHR

  • Difficult handwritings to read and interpret.
  • Forgery of documentation by health workers
  • Loss & damage to patients records in cases of fire outbreak
  • Breech of confidentiality to patient records incase of handling by unauthorized personnel.
  • A lot of workload to the RN especially where forms have to be collected from a different department e.g. laboratory request forms

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EHR PRACTICE & THE FUTURE

ADVANTAGES OF EHR

  • Documentation is password protected hence cannot be accessed by unauthorized staff.
  • Patient records confidentiality is better than paper records.
  • Forging of documentation is impossible as all documentation is time stampeded hence keeps all staff keen on timely documentation documentation.
  • Delay of services is minimized authorization can be done remotely.

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CHALLENGES OF EHR

  • Costly to implement
  • Documentation is compromised in cases of internet downtime or system maintenance.
  • Requires you to revert paper documentation and follow down town process
  • Once information is entered deletion or correction is tracked wrong entries.
  • Demands computer literacy.

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ROLE OF EHR IN PATIENT SAFETY

  • Discourages documentation to wrong patients by keeping the practitioner off patient not under their care. It also tracks people accessing charts on patients you are not the care provider
  • In cases of delay drug administration the system puts a red alert alarm.
  • In case of any prescription containing an allergen to the patient the system ALERTS such prescriptions.

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CONT……..

  • The accuracy in vital sign observations provides real time interventions in cases of deviations from normal ranges.
  • Procedures cannot proceed in documentation if the mandatory checklists have not been done. A factor that discourages shortcuts for safety of patients

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Our Experience at Year 1

  • November 5th marked one year since we went live with fully integrated EHR, MEDITECH EXPANSE.
  • It’s been a monumental period for AKUHN with lots of benefits realized. Despite the painful start as we transitioned from paper, a formidable positive impact has been noted with staff fully adjusting to EHR.
  • At the core of this is evidenced based improved standards of care and overall patient and provider experience.
  • We have witnessed reduced TAT at various levels. This has been enabled by real time sharing of heath data between various providers/sections.
  • Health data report extraction and analytics has been simplified by the use of standard/custom reports and surveillance tools available MEDITECH EXPANSE.
  • Generally, MEDITECH Expanse is an intuitive and transformative system that we wished came in a decade ago.

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REFERENCE

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  • National Coordinator for Health Information Technology (ONC)  March 8, 2022.
  • Centers for Medicare & Medicaid Services 6 Sept 2023

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