Electronic Health Records
Health Information Technology
As defined in McGonigle and Mastrian (2018) by the Health Information Technology for Economic and Clinical Health (HITECH) Act, Health information technology (HIT) is comprised of “hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by healthcare entities or patients for the electronic creation, maintenance, access, or exchange of health information” (p.149). HIT has been promoted as a key element in the National Quality Strategy (NQS) to achieve three aims: better care, affordable care, and healthy populations and communities.
Electronic Health Records
To improve the quality of care through HIT, electronic health record (EHR) system implementation has become a top priority in US hospitals and healthcare organizations, underpinned by national initiatives such as the Health Information Technology for Economic and Clinical Health (HITECH) Act and EHR incentive programs such as Meaningful Use (MU) (Centers for Medicare and Medicaid Services, 2013). Beyond the goal of stimulating the implementation of EHR systems, the MU initiative was developed as an incentive program to assure that EHRSs are used according to standards that achieve quality, safety, and efficiency measures (Centers for Medicare and Medicaid Services, 2013). We will learn more about MU later in this lesson.
Numerous terms have been used over the years to describe the concept of an EHR, leading to confusion about the definitions. EHR has been used as a generic term for all electronic healthcare records and the related systems and recently became the favored term for an individual’s lifetime computerized record. In most usage, the term EHR is used to mean both the displayed or printed record and the supporting software system (EHRS). A basic definition of an EHR is a database of an individual’s healthcare data during healthcare encounters. An EHRS is the database management software enabling the many functions needed to create and maintain an EHR. Another simple definition is that an EHR is comprised of any patient data stored in electronic form. Other, lengthier definitions build from this premise. Updates to the electronic record are restricted to authorized clinicians and staff. Patients may be shown data in an EHR but do not have control. The EHRS usually includes software to manage: a data repository (the EHR database), practitioner order entry (POE)—also known as computerized practitioner order entry (CPOE)—clinical decision support (CDS), and practitioner documentation.
One of the major potential benefits of electronic health information is the ability to engage patients in their care and provide venues to access caregivers virtually, using email and web platforms, providing ease and convenience to the patient. The healthcare sector is just beginning to realize the potential value of the large pools of de-identified data at its disposal. This aggregate data, also known as secondary or big data, can be used to improve care, discover patterns, reduce costs, support research, and identify and respond to consumer preferences. The process of tapping this data is known by many terms, such as analytics, data mining, knowledge discovery in data bases, or business intelligence. The result is that the analysis provided can support better and timelier decision making, decrease risks, and discover valuable insights if appropriate tools are used. Harper (2013) suggested improved staffing models based upon patient information as one potential application for nurses.
Electronic record systems are built around large databases that allow input, storage, and retrieval of specific data for use in a meaningful way that can support other functions, such as decision support, results reporting, and order entry. Clinical documentation and clinical messaging are other basic functions. Use and reuse of data relies upon the collection of structured data that follows a format that supports manipulation.
In the following activity you will be presented with a patient being interviewed by a nurse practitioner. You can download the
SOAP Note TemplateLinks to an external site.
to fill in as you follow along with the scenario.
Lower Back Pain
After completing the activity you can view the answer key here.
Lower Back Pain Answer KeyLinks to an external site.
EHRs provide users with enhanced versions of the functionality found in traditional paper-based health records. The addition of computer technology and digital data improves and expands on the basic set of functions.
Current functionality includes:
· Point-of-care (POC) access by practitioners
· Support for multiple users to view data on same patient at the same time
· Results review (laboratory, pathology, imaging, notes, etc.)
· Quality metrics
· Electronic communication
· Order management
· Patient monitoring in real time
· Patient summary displays
· Patient support
· Medication administration record
· Population health.
· Bar code medication administration.
· External reference resources.
· Billing (Payne, 2016; Hydari, Telang, & Marella, 2015).
· Centers for Medicare and Medicaid Services. (2013). Meaningful use. Baltimore, MD: Centers for Medicare and Medicaid Services. Retrieved from www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html.
· Harper, E. M. (2013). The economic value of healthcare data. Nursing Administrator Quarterly, 37(2), 105—108. https://journals.lww.com/naqjournal/Abstract/2013/04000/The_Economic_Value_of_Health_Care_Data.4.aspx
· Health Information Technology for Economic and Clinical Health Act. (2009). Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hitechact.pdf
· Hydari, M. Z., Telang, R., & Marella, W. M. (2015). Electronic health records and patient safety. Communications of the ACM, 58(11), 30-32.
· McBride, S. G., Tietze, M., & Fenton, M. V. (2013). Developing an applied informatics course for a Doctor of Nursing Practice program. Nurse Educator, 38(1), 37-42. https://pubmed.ncbi.nlm.nih.gov/23222633/
· Payne, T. H. (2016). The electronic health record as a catalyst for quality improvement in patient care. Heart, 102(22), 1782. doi: http://dx.doi.org.proxy.chamberlain.edu:8080/10.1136/heartjnl-2015-308724
· Resnick, C. M., Meara, J. G., Peltzman, M., & Gilley, M. (2016). Meaningful use: A program in transition. Bulletin of the American College of Surgeons, 101(3), 10-16. https://bulletin.facs.org/2016/03/meaningful-use-a-program-in-transition