Abstract
Electronic Health Recording system has had a tremendously positive effect on the process of documentation within health care institutions. The article starts by giving an introduction to the meaning and implication of EHRs to the entire health care system. Ways in which the implementation of the technology benefits the nursing industry. There is then the discussion on how EHRs were made available researched on and the related resources. The article further explains the technicality and suitability of the information provided to the audience followed by a personal view on the topic and a conclusion on the implementation and use of the EHR system.
Introduction
An electronic Health Record could be referred to as a longitudinal electronic record that shows a patient’s health information. It is normally generated to serve multiple health care delivery systems. So much information is included within the record with a clear definition of the level of medications done on individual patients within specific periods. Electronic Health Records systems (EHR) are constituted of several technologies, these include virtually all patient data and certain types of data on medications (Thede, 2010).
Other processes supported by EHR include decision support which comprises services such as preventive service reminders, alerts concerning the possibility of the use of drugs, and guidelines on the clinical based reports. Part of the modern EHR system operates according to specific operations and has the capability of operating within specific health systems in health institutions. The functions of EHR vary depending on the need within the healthcare system. The records are essential towards the improvement of the quality of health and management of entire health care delivery. This system only works within institutions working on healthcare-related issues (Thede, 2010).
Electronic Health Records
Topic Availability
The topic was identified after recognizing the fact that various hospitals had implemented various forms of EHR documentation that were found very useful. There seemed to have been some difficulties on the side of nurses on ways of putting up proper documentation at the points where care delivery was necessary. Nurses gave preference to Electronic Health Records (EHRs) system of documentation rather than manual way because it was proved to be very efficient. Research by Pub Med between the years 1984 and 2004 recorded on the purported use and implementation of an EHR system, the response from most of the nursing and healthcare institutions was found to be positive.
The research was done by Hobbs concerning attitude and the necessary computer-based knowledge that nurses require for general understanding and use of EHR technology. Studies by Krampf and Robinson also researched the issue of the attitude nurses had towards computer technology used within EHR systems. The use of Health Information Technology for Economic and Clinical Health Act (HITECH), assisted with the financial incentives towards healthcare providers who adopted Electronic Health Records which helped in the improvement of their system (CMS Office of Public Affairs, 2010; Hobbs, 2002; Krampf and Robinson, 1984).
The Health Information and Management Systems Society developed some model that was useful in defining important aspects of the EHRs system. This covered the aspects such as security and confidentiality of the records and information used in supporting clinical practices. Healthcare Institutions are required to Install EHRs for better provision of health care services (Thede, 2010).
Information Availability
The resources found were very descriptive and at the same time assesses the functionality level of the Electronic Health Records system documentation. According to the information given not everyone has become enthusiastic about the use of EHRs. This reveals the reason why the adoption rates were low and varied widely within health care institutions. There are several problems encountered in the process of implementing EHRs, the problems are both organizational and behavioral. These could be attributed to the attitude of nurses towards the use of modern technology which might as a result of inadequate education on the use of the system (Thede, 2008).
The information on this technology helps in increasing people’s awareness and control over their general health. It grants individuals the sense and necessity of attaining complete by paying attention to various activities and needs that lead to sustenance of good health. Overall individuals’ health touching the physical, mental, and social aspects, are all availed through the information provided on this technology. This, therefore, qualifies the EHR system not only as part of caregivers but also individuals who care about their well-being (Frampton et al, 2009). The information on good communication skills helps the nurses during the processes of convincing patients about their medical care needs. The information provided on the system has been addressed appropriately despite personal neglect (Thede, 2008).
Personal Views
The documentation of patients’ data and regulations that safeguards the integrity and confidentiality of the data is of great benefit. The information offers security to the testing and assessment procedures of the patients and also sanctions to those who attempt to breach rules safeguarding the use of the EHR system. The technology makes patient data not physically accessible to the public and also well protected against any environmental damage.
The patient records are protected and controlled by the use of the new technology that provides reliable records of those that might have access to patient data. The use of electronic signatures within EHR provides the identities of the users who might want to share patient data and prescriptions. This standard helps in maintaining message integrity by the use of electronic signatures (Thede, 2010).
This technology helps in protecting the patient’s privacy by concealing their medical information. Electronic Health System integrates all sources of security ensuring that the confidentiality and privacy of health information are secure. This has guaranteed the patients access to appropriate and quality care without any fear of loss. It eliminated the issue of patient discrimination within the job market based on their medical status. This technology has enabled most medical institutions to invest in information system technology ensuring that the weak security once experienced over patient’s data is eliminated (Thede, 2010).).
The information on the system provides various communication tools that could be used by the caregivers to facilitate health provision. Through these tools, the necessary guidance and support are provided that could help in enhancing the patients’ confidence in managing their condition and understanding further, their medication status. There is the possibility of providing self-management support plans to the patient by the nurses which facilitate the processes of helping them manage their conditions appropriately and consistently based upon their health records provided within the EHR system. There is a need to consider the psychological and social context of the patient’s lifestyle and the impacts these have on self-management support that could affect the nature of the healthcare delivery system applied (CMS, 2011).
The other weakness that accompanies the system is the idea of indicating in the records that the patient is non-compliance should not be the case; instead, they should find a way of teaching the patient on the importance of adhering to medical prescription until proven otherwise by medical experts (Mitchell and Begoray, 2010). Patient-centered care further requires that caregivers advocate for patients’ good and try their level best to offer safe and effective treatment to patients. The patients should adhere to the suggested lifestyle changes prescribed to help promote a better outcome. The use of an EHR system requires that patients are supposed to be rational information users. This requires the help of nurses in understanding and using the prescribed information from medical doctors.
To assist patients, nurses should be aware of the need to inform them about recovery from sickness and how to manage symptoms that may be a result of too much commitment to work. Through this, the nurses could also educate the patient on the kind of lifestyle that affects health and the benefits of adhering to medical prescriptions. Nurses utilize their role as educators on non-compliance patients to make them understand better.
However, it is necessary for Health information obtained from patients to be individualized as per the agreement between the patient and the practitioner and the readiness of the individual to learn. Education programs should be negotiated between caregivers and the patient and focused specifically on individual needs. There is enough information on the suitability and security of using part of the system known as My Personal Health Record (MyPHRSC) in South Carolina (CMS, 2011).
One approach that could be utilized in increasing the acceptance of Electronic Health Recording systems is usability testing which helps in determining the suitability of the system to its users and its functions. The issue of testing the practicability of the system involved so much interaction between computer science, information science, and psychology. The testing process takes different forms and also seeks to assess the level of credibility of information technology such as clinical information systems, electronic documentation, and application software. The application of the Electronic Health Record system comprises of different application purposes (Thede, 2010).
Conclusion
The implementation and use of the Electronic Health Recording system provided a source of help to nurses who are more concerned with the duties of providing people with treatment, prevention measures, and overall management of their health. This is also ensured through the help of professional services from qualified physicians. These services require adequate knowledge and must be performed based on already set policies and standards that govern the healthcare system. However, the industry faces some challenges which include costs and the complex processes that are followed to ensure a quality result.
References
CMS Office of Public Affairs. (2010). Electronic Health Records at a Glance. Web.
Centers for Medicare and Medicaid Services (CMS). (2011). PHR Pilots: CMS Personal Health Record Pilots in South Carolina, Arizona, and Utah. Web.
Frampton, S. B., Horowitz, S., & Stumpo, J. (2009). Open Medical Records. American Journal of Nursing, 109 (8), 59-63.
Hobbs, S.D. (2002). Measuring nurses’ computer competency: an analysis of published Instruments. Comput Inform Nurs, 20 (2), 63-73.
Krampf, S., & Robinson, S. (1984). Managing nurses’ attitudes toward computers. Nurs Manage, 15(7), 29- 34.
Mitchell, B. & Begoray, D., L. (2010). Electronic Personal Health Records That Promote Self-Management in Chronic Illness. OJIN: The Online Journal of Issues in Nursing, 15 (3).
Thede, L. (2008). The Electronic Health Record: Will Nursing Be on Board When the Ship Leaves? OJIN: The Online Journal of Issues in Nursing, 13 (3).
Thede, L. (2008). Informatics: Electronic Personal Health Records: Nursing’s Role. OJIN: The Online Journal of Issues in Nursing, 1(14).
Thede, L. (2010.) Informatics: Electronic Health Records: A Boon or Privacy Nightmare? OJIN: The Online Journal of Issues in Nursing, 2 (15).