Introduction
The recent challenges that have faced the health care provision in America and the world demonstrate that information technology through Electronic Health Record can enhance the administration, application, and implication of the health care system. Electronic Health Record (EHR) is an evolving concept in the health system that borders the systematic collection of health information about patients. This topic is significant because it addresses the critical elements in managing digital format information through a network interface that connects enterprise-wide information systems. The research will utilize a qualitative case study approach to understand the impact of EHR in nursing practice. The study will draw sources from EBSCOhost and Proquest databases available through the Capella University Library. Search teams will be limited to the Electronic health record, impact, and nursing practice.
Annotated Bibliography
Graber, M. L., Byrne, C., & Johnston, D. (2017). The impact of electronic health records on the diagnosis. Diagnosis, 4(4), 211-223.
The authors highlight the significance of EHR in reducing diagnostic errors and promoting patient safety. The source underscores how EHR is a universal tool that integrates elements of care information technology and its use in the diagnostic process. EHR conceptualizes a systemic approach to inclusive documentation of a patient’s encounters that entirely allows for the streamlining and automation of workflow in the broader healthcare setting. The source’s findings show that EHR technologies increase safety by enabling evidence-based decision support, outcome reporting, and quality management.
The source is credible in evaluating how EHR and health information technology improve nursing practice’s diagnostic and efficiency. Graber, Byrne, and Johnston (2017) outline that EHR has vastly reduced medical errors by providing physicians with decision support. Fast access to medical reports and literature enhance the proliferation of ongoing efforts to improve healthcare efficacy. Hospitals that utilize EHR systems aim at providing quality healthcare delivery, safety, efficiency in patient management, and reduced health disparities. Today manual systems create room for errors of omission and commission, affecting the delivery of quality healthcare systems.
The source relates to a vast literature examining the emerging challenges of diagnostic errors and how they affect healthcare delivery. The technology improves issues of the compilation of hospitalization as well as ambulant services of the patient. It also enhances access to vital information with browser capabilities that refer to given coding concepts and information on medical procedures. Although technology comes with a host of challenges, the benefits outweigh the challenges, and information technology in hospitals and health institutions is one step ahead in safeguarding life. Electronic Health Record provides admittance to a large amount of clinical data, enhancing the level of knowledge of efficiency in medical practices.
Stevenson, J. E., Israelsson, J., Petersson, G., & Bath, P. A. (2018). Factors influencing the quality of vital sign data in electronic health records: A qualitative study. Journal of Clinical Nursing, 27(5-6), 1276-1286.
The authors examine the principles of EHR. The literature on EHR stems from the need to address existing challenges. For this reason, Stevenson et al. (2018) investigate many reasons for inadequate documentation of vital signs in EHR. To implement an electronic health record in the facility, hospital administrators take a more organic view and consider how healthcare facilities will integrate electronic systems with the already existing business process. The authors note that the primary step includes defining what electronic system means throughout the health institution.
The source is authentic in providing in-depth knowledge of using EHR to help nurses detect and respond to patients’ deterioration. The source offers credible valuable data in examining the need for EHR and the challenges nursing practitioners encounter. Every healthcare environment functions differently, making it hard to develop an electronic health system that is one-size-fits-all. The primary mechanism to achieve the objective of including vital signs in the EHR calls for the customization interface EHR. The physician creates an ideal system with record standardization within each provider environment. Healthcare practitioners should customize their EHR through regulations. Using EHR in the hospital would improve efficiency in service delivery and reduce the cost of errors that come with data systems. The cost of integrating EHR in hospitals may look high, but the technology will improve department communication and the effective management of patient data.
Documenting vital signs in EHR has limited focus. Nursing practice must focus on the association between monitoring a patient’s progress and attending to emergencies. () note that the primary step includes defining what electronic system means throughout the health institution.
Vehko, T., Hyppönen, H., Puttonen, S., Kujala, S., Ketola, E., Tuukkanen, J., … & Heponiemi, T. (2019). Experienced time pressure and stress: electronic health records usability and information technology competence play a role. BMC Medical Informatics and Decision Making, 19(1), 1-9.
The journal article the role of nurses in their informatics competence to achieve high efficiency of EHR. The authors draw on the nationwide survey of working-age registered nurses to show that most nurses experience challenges with their EHRs. Therefore, informatics competence among nurses plays a critical role in promoting the part of this technology.
The source is credible, given its methodology. The authors connect the EHR usability factors with the nurse’s informatics competence and the psychological distress they experience (Vehko et al., 2019). Training and staffing issues are challenging because it needs the deployment of medical informatics, which is expensive to pay for. As a result, most nurses associate the competence factors with training health providers on the logistics of using electronic health systems. New employees will require constant training for efficiency, whether permanent or temporary. Competence implies that the system should provide multimedia data from specialists within cardiology, radiology, and many other departmental medical health units. The hospital will train nurses and all practitioners on using EHR. The organization factors will depend on the policies, social norms, and training programs, which may increase the cost of implementing EHR. However, the technology will empower nurses and workers, allowing effective workflows. The outcomes of such a policy will be improved delivery of health care.
The study shows that a lack of proper training and technological competencies led to high time pressure and poor system use. Hospitals should set appropriate expectations by promoting and accepting the data collection and storage change process. A careful plan of transition from the paper plan process to the final deployment of the electronic health record promotes the decision-making of nurses and other practitioners. Hospitals should choose the technology partner in the most appropriate way to work with the health provider on the advisory schema for the entire electronic health system. Electronic Health Record is a software technology that advances at a rapid rate. The system requires frequent and constant updates, which comes with continuous training needs for improving nurse competence.
Kruse, C. S., Mileski, M., Vijaykumar, A. G., Viswanathan, S. V., Suskandla, U., & Chidambaram, Y. (2017). Impact of electronic health records on long-term care facilities: a systematic review. JMIR Medical Informatics, 5(3), e35.
The source conducts a systematic review to identify the EHR system’s benefits. The standard conditions of implementing the EHR help address nursing informatics (Kruse et al., 2017). EHR enhances the value of health care by making it possible for health institutions to capture information about the patient regarding assessment, clinical reports, billing reports, and the patient’s medical history. The success of Electronic Health Record and the implementation of clinical documentation must be concise with workflow designs and engage specific measures that would lead to the realization of medical benefits of customization and information interface across hospitals.
The source is credible because it articulates critical issues in EHR. The systematic review from PubMed and Medline databases helps achieve data reliability in EHR use. In essence, the source demonstrates how the use of EHR impacts the satisfaction of the physician and patient. The authors give an overview of the electronic health record features, the underlying functions, implementation and application, and the possible implication of the whole plan. Implementing EHR will come with platforms of improved communication between physicians and all parties. The technology allows for better access to the medical history of the patient. For this reason, the hospitals will allow their doctors to follow up with patients as critical factors in tracking continuing care. Hence, it is imperative to implement EHR in healthcare, regardless of cost.
The source reveals that the implementation of EHR is effective in healthcare facilities. Most technologies that establish EHR have led nurses to improve clinical documentation management. The immediate impact of this is its role in improving decision-making. The source analyses how Electronic Health Record would lead to efficiency in clinical research, improving the modes of data collection and storage within the health care system.
Conclusion
Electronic Health Record encompasses handling data in a comprehensive form. It captures the medical history, demographics, immunization status, medication status, laboratory test results, billing information, and radiology images. The annotation explains that hospitals can achieve EHR benefits if the information system is widespread and interoperable at regional and national levels. Therefore, various methods share the medical data, thereby avoiding the possible failure that can violate the patients’ privacy and entirely injure them. Concerning this, the best and most accurate practices in software engineering and medical informatics must be integrated. Hence, connecting many electronic medical systems reflects why health institutions should purchase the Electronic Health Record. However, the application of this system must meet specific criteria such as cost and legal provision since it involves human affairs. This implication involves obstacles in line with implementing the Electronic Health Record, such as training, staffing, identity, and security.
References
Graber, M. L., Byrne, C., & Johnston, D. (2017). The impact of electronic health records on diagnosis. Diagnosis, 4(4), 211-223.
Kruse, C. S., Mileski, M., Vijaykumar, A. G., Viswanathan, S. V., Suskandla, U., & Chidambaram, Y. (2017). Impact of electronic health records on long-term care facilities: systematic review. JMIR Medical informatics, 5(3), e35.
Stevenson, J. E., Israelsson, J., Petersson, G., & Bath, P. A. (2018). Factors influencing the quality of vital sign data in electronic health records: A qualitative study. Journal of clinical nursing, 27(5-6), 1276-1286.
Vehko, T., Hyppönen, H., Puttonen, S., Kujala, S., Ketola, E., Tuukkanen, J., … & Heponiemi, T. (2019). Experienced time pressure and stress: electronic health records usability and information technology competence play a role. BMC Medical Informatics and Decision Making, 19(1), 1-9.