Posted: June 26th, 2022
Your practice as a registered nursing assistant is integral to the use of electronic communication and technology.
Registered nurses are required to keep track of the care they provide in a client/patient medical record. This record is becoming increasingly electronic.
Find out how electronic health records can be used to support nursing practice and patient care.
Discuss the main problem with electronic health records, and the risks associated with their use.
What strategies can you use as a registered nurse to minimize these risks?
An electronic health record (e-health record) is a record that contains the patient’s medical information in digital format.
An electronic health record is a digital version of the patient’s medical history that has been maintained over time by a healthcare provider.
Electronic health record systems were introduced in hospitals in 2009 by the National Health and Hospitals Commission.
When people had the opportunity to register for the system, the technology was launched in July 2012.
The electronic health records contain information that will allow for a more efficient flow of work by the clinician.
The benefits of the new technology in a hospital are discussed, including reduced medical errors and improved quality (Harrington 2006 p.145).
The paper also discusses the potential risks and drawbacks associated with electronic health records, including disruptions in workflow due to the introduction of new technology. It also lists the mitigation measures that can be taken to reduce these risks.
Electronic Health Records in Nursing and Patient Care: Benefits
Health care providers can access accurate and complete information about patients to improve their diagnosis and patient outcomes.
This information is essential for providing accurate advice and enhancing diagnosis.
It is vital to have accurate information in order to minimize and eliminate medical errors.
The nurse’s work-life balance will be improved if they have more information about patients.
Electronic health systems have made it possible to remotely access patients, reducing the number of cases in which nurses or other medical professionals work late at night (Stefane 2010, page 141).
Nurses can work from their homes, allowing them to maintain a healthy balance between family life and professional duties.
With electronic health records, nurses don’t have to travel back to their offices to retrieve the manual information about patients. They can also return to the emergency providers after the call (Hoffman 2016, page 120).
Remote access means that patients can receive more efficient care and less time.
EHRs reduce errors, increase patient safety, and support better patient outcomes.
The information is then manipulated so that it can make a difference to patients. An EHR not only stores records about a patient’s medications but also syncs automatically to determine if there are any issues when a nurse prescribes a medication.
The nurse is also notified of possible conflicts due to the new medication. (Hristidis 2009 p. 321).
E-health records can also alert the nurse to any safety issues as soon as they arise.
This is important for both the patient and the nurse as it helps to avoid more serious consequences, which can lead to better patient outcomes.
To determine the extent of life-threatening medical conditions in a patient, a nurse can use the primary information from an EHR. This would allow the appropriate adjustments to Medicare. (Kelley 2016, p. 180).
Even if the patient is not conscious, this can be done.
Electronic health records can also be used to quickly and efficiently identify and correct any anomalies.
Contrary to paper-based systems, where such corrections could take years and retrieving the information would take much time.
Quality and convenient health care. Electronic health records can help improve the quality of health care and make it more convenient for patients and providers.
Quality health care enhances all aspects of patient care, including communication, education and efficiency.
Electronic health records encourage healthier lifestyles through better nutrition and increased physical activity.
Doctors can now have their prescriptions ready and ordered electronically.
The nurse can still be contacted by the team to file insurance claims.
Participation of patients is increasing: Electronic health records allow nurses and patients to work together in making decisions that are crucial in managing various medical conditions.
Patients can be involved in the management of chronic conditions such as diabetes, obesity, and asthma.
High-quality care is possible through electronic health records. Patients can provide detailed, complete and extensive information about all aspects of their medical evaluations.
Nurses can also provide follow-up information from their offices.
These follow-ups can include reminders for follow-up care, selfcare instructions and links to other resources (McCormick 2013, page 94).
Electronic health records allow for communication between patients and nurses.
The nurse can send patients e-mails and electronically schedule appointments.
This allows for quicker communication between nurse and patient. It also helps to identify symptoms earlier and position the nurse in a better position to access the patient more frequently.
Information is more readily available: Electronic health records make it possible to access patient information at any time and from any place.
According to Stefane (2010), p. 166, the nurse has immediate access to all the information that he requires at any given time.
This allows for quick decisions about the patient’s health.
For safe and efficient care, accurate and reliable information about the patient’s health is essential.
The nurse has access to accurate and complete information about the patient’s medical history and health.
These factors lead to better patient experiences, which in turn leads to better patient outcomes.
Nurses use the information from EHRs about patients and disease registries to track patient care and facilitate quality improvement discussions at their conventions and forums (Steen 2011, page 102).
Electronic Health Records and the Risks Associated with EHRs: The Main Issue
The main problem with electronic health records is finances.
Financial issues include maintenance costs, adoption costs, implementation costs, and decreases in revenue.
Adoption and implementation cost include the costs of buying and installing the hardware and software.
This includes the conversion of manual paper charts to electronic charts and retraining end-users to enable them to use the new technology (Yoshihashi 2014 p. 263).
When all these costs are added together, they can reach very high levels that would require hospitals to make huge investments to roll over the program.
The time spent training end-users would mean that there is less time for patient-nurse relationships.
This could result in patients not being as well cared for as they need.
Maintenance costs can also be very costly.
The reason is that the hardware needs to be replaced at a specific time and the software must be updated on a regular basis (Stefane 2010, page 158).
The nurses must also be trained to use the latest software.
Because electronic health records are not a financial benefit to nurses, but rather to third-party payers, the costs of implementation, adoption and ongoing maintenance are all compounded.
These financial benefits accrue in the form of errors avoided and improved efficiency which, in turn, results in a decrease in claims payments.
The high upfront costs and misalignment in incentives are a major obstacle to adoption and implementation electronic health records, especially for infant practices (Stefane 2010, page 366).
The main obstacles to the adoption and implementation and maintenance of electronic health records are, according to most nurses, the adoption, implementation and maintenance costs.
The greatest dangers that electronic health records can expose are privacy and accuracy of stored data, as well as depreciation of patient information due to periodic time updates (Stefane 2010, page 396).
Access to electronic health records and patient information can be easily accessed by unauthorized persons.
Without the consent or authorization of the patient, it is a breach in security for any other person to have confidential patient information.
There are also risks associated with decreased interaction between the patient’s nurse and the patient.
The nurse may overrely on electronic medical records to provide information about the patient.
The nurse might neglect or omit some changes or advancements in the patient’s medical condition.
There are still possibilities for malpractice.
These types of malpractice include data loss or destruction, incorrect corrections to medical records, or inaccurate data entry (Aspden 2003 p. 374).
If these malpractices aren’t identified and the appropriate steps taken, the patient may be subject to stray prescriptions.
Therefore, it is important to make the patient the primary source of information. The electronic health records are also a reference and backup guide.
During the transition from manual data entry into electronic health records, mistakes can also occur.
Medical identity theft is another major concern with electronic health records.
This could have serious health implications as the patient’s records would contain incorrect information (Steen 2011, p.210).
The patient’s insurance company would also feel the consequences. They will be billing for services that are not their policy holders.
In the long-term, the patient’s treatment would be so misinformed that neither the nurse or the patient could realize in the shortest time how to correct the situation.
The software and hardware used to create electronic health records are susceptible to mechanical and technical breakdowns.
All data in these systems can become unavailable or inaccessible during periods of technical problems and breakage.
This means that it is very difficult to care for patients if the system has technical problems.
Patients can access all information regarding their medical condition through electronic health records.
Some information may be kept secret from the patient.
Patients may be anxious or fearful if they have access to this information.
This is especially true for information the patients don’t understand or have no idea about.
This can lead to side effects stress in the patient that could cause further medical complications.
Strategies to Minimize the Risk
The majority of the above risks are easily manageable because they either result from negligence or failure to adhere to the set-aside provisions.
The security issues and errors that result from negligence would be addressed as I deploy strategies to mitigate the risk.
Security measures such as firewalls, antivirus software, and intrusion software would be discarded. They would help to protect the integrity of the data stored in the electronic health records. (Stefane 2010, page 469).
I would insist on some policies and procedures to ensure the confidentiality and privacy of patients.
These measures include ensuring employees are not allowed to share their ID cards with anyone and logging off after leaving a terminal (Wegman 2011, page 127).
I recommend that the institution designate a security officer to work with the IT team.
Random audits should be conducted at every hospital to ensure that hospital policies and provisions are being followed.
It would be vital to track such information as the contents of each item, their duration and who created them.
This information would be used to identify any missing or misplaced information.
However, it is possible to track unauthorized views, access due to errors, or inadvertently (Stefane 2010, page 510).
The electronic health record has had a profound impact on the operation of the health sector.
This has allowed for a more efficient and quick way to perform tasks, which has resulted in better patient care and nursing practice efficiency.
While electronic health records offer many benefits, there are some ethical concerns and risks that can be overlooked.
The security of patient information in electronic health records is a serious concern.
Patients’ information should be kept private and confidential.
Aspden, P 2003. Patient Safety: Achieving New Standards for Care. 2nd Edn, National Academies Press. Leicester.
Harrington, L 2006. Usability Evaluation Handbook for Electronic Health Records. 3rd Edn, HIMSS Chicago.
Hoffman, S 2016. Electronic Health Records and Medical Big Data. 1st Edn, Cambridge University Press Los Angeles.
Hristidis V 2009, Information Discovery on Electronic Health Records. 3rd Edn, CRC Press Galway.
Kelley, T 2016. Electronic Health Records for Quality Nursing and Health Care, 5th edn, DEStech Publications, Inc, Gainesville.
Kulkarni (VA 2006), Implementation of Electronic Health Records. Modeling and Evaluating Healthcare Information Systems to Improve Quality in the United States Healthcare Industry. 3rd Edn, ProQuest.
McCormick KA 2013, Healthcare Information Technology Exam guide for CompTIA Healthcare IT Technician Certifications and HIT Pro Certifications. 4th edn McGraw Hill Professional. New York.
Medicine, IO 2012 Health IT and Patient Safety: Building Safer Systems For Better Care, 3rd edn National Academies Press, Chicago.
Staggers N 2014, Health Informatics An Interprofessional Approach 5th Edn, Elsevier Health Sciences New York
Steen, EB 2011. The Computer-based patient record: An essential technology for health care, 2nd edn. National Academies of Florida.
Stefane, M 2010. Healthcare and the Effects of Technology: Developments Challenges and Advancements. Developments Challenges and Advancements. 3rd Edn, IGI Global Manchester.
Wegman, DH 2011. Incorporating Occupational Data in Electronic Health Records. Letter Report, 3rd edn. National Academies Press. Florida.
Yoshihashi AK 2014, Health Informatics Practical Guide for Healthcare and Information Technology Professionals. 6th edn. Lulu.com. Chicago.
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