Electronic Medical Records Documentation and the Role of the Nurse

Nursing

Electronic Medical Records, Documentation, and the Role of the Nurse

Efficient use of time is one of the primary methods healthcare professionals use to save lives. When there is very little time available, and decisions have to be made with acute accuracy, it is of primary concern to have access to all necessary information immediately. Nurses and other healthcare professionals have long enjoyed this access due to charting procedures implemented by hospitals over a century ago (Bernd & Fine, 2011). However, the immediacy is has not been there because paper charts require some amount of access time. Recently, because of the advances in computer technology, nursing has seen a significant change in the type of charting that occurs. The same documents apply, but nurses have better access to a patients file because charts have entered the computer age. Thinking only of efficiency, electronic medical records (EMR) have provided nursing with a valuable tool that can be used to enhance patient care in many different ways. The focus of this paper is both how and if the advent of electronic record keeping has assisted nurses with patient care, and what systems are being used.

EMR in Clinic and Hospital Settings

Even though the development of EMR is a relatively recent phenomena, its implementation in both the hospital and clinic settings has been rapid. Although nurses have been charting patients progress for many years they have not had the immediacy that they are offered with EMR. Both the independent clinics and hospitals use it for this reason, but the technology has different roles in these two arenas of healthcare.

A hospital is much more of an acute care facility than a clinic, so nurses need to be able to access information quickly out of necessity. Flipping through a paper chart causes unnecessary delays in patient care that could be the difference between life and death. Although that statement may be a little too dramatic, it is possible that the use of EMR could save a patient's life. The main issue for hospital use of EMR is that every department often has its own system and integrating these into a single, cohesive unit can be next to impossible (Rowley, 2010). But, once a hospital has decided to go with a system that is based on an intranet platform so that all of the different departments can talk to one another, the implementation can be rather easy. Although, initial costs can be large, once the IT is set up, it is very easy for everyone to plug into one system. Robert Rowley, MD, (2010) a clinical specialist in EMR, said that "The hospital's EHR is, as one would expect, locally housed. After all, the connections with the department's systems is internal, and custom, and best handled by a local enterprise-type system." This localized housing is an advantage that the hospital has over a clinic.

Rowley (2010) goes on to say,

"A physician practice [clinic] has records that are longitudinal (rather than episode-of-care), and are internal to that practice (rather than all consultants writing in the same chart, as is the case in the hospital record). They deal with hundreds of different pharmacies, not just the one hospital pharmacy department. Generally, there is not in-house x-ray or imaging department, so that connection to such data is an external link. Often, more than one lab is used for the practice's patients, often determined by the patient's particular health plan coverage and preferences."

It is easy to see the challenges inherent for the design of an EMR system in a clinic setting vs. A hospital. Although the hospital may be large, all of the facilities are on-site, whereas a clinic has to use whatever peripheral healthcare services are available according to a patient's preferences. Therefore, clinics often prefer to use a system that is web-based. It allows them to talk to other providers quickly without the expense of maintaining an in-house EMR system (Rowley, 2010).

Nursing Benefits of EMR and Intake Assessments

The actual benefits and problems associated with EMR will be discussed in another section, but intake assessments fall into both categories. Intake is one of the most tedious tasks a nurse has to do. With the advent of EMR it is easier to complete this task in some respects, but, for the nurse, it has become more of an issue. In some instances it seems to actually make the intake process longer because the nurse still has to fill out the information, but there because of the ease of electronics for everyone, there is often more information to fill out. So, the benefit is that the information can be instantly uploaded everywhere in the hospital or system, the fact that it can take a nurse away from his or her duties for a more extended period of time is a negative aspect.

Disadvantages vs. Advantages of EMR

Disadvantages

It is actually easier to talk about the disadvantages because there are so few of them. In reality, there are only two which are very pressing. The first is that many people balk at the installation of an EMR system. One of the reasons for this is that it is sometimes difficult for people who have not been using computers their entire lives to either trust them or to use hem with any effectiveness. Doctors and nurses are intelligent people who have passed through some of the most demanding academic challenges that exist in the educational world. However, this does not mean that the individual has any confidence in their ability to use a computer. This fear is a big reason that in one survey 81% of independent doctors did not use an EMR system (Robles, 2009). This is problematic because so many healthcare systems are completely paperless now, so they have to take the time to convert that patient's health record to their EMR system.

The other disadvantage that some see, and it is a much bigger issue than fear of adaptation, is the confidentiality of the patients record. This is mainly a legal concern because hospitals and clinics always worry about compliance with the various regulations that exist. The problem is exchange of information via an electronic network and whether that data will be secure or not. A health information exchange (HIE) allows a doctor to "share a patient's EMR from one facility with another facility, and vice versa. This allows a patient to visit different facilities without having to request a copy of her medical records be sent each time. In practice, however, these arrangements are difficult to implement on a large scale and have only resulted in regional networks, known as regional health information organizations" (McCarthy, 2010)

But, this can be problematic because there are some networks which are not as secure as others.

"A main concern, and the central topic of this Note, is the privacy, or lack thereof, of data stored in PHRs. PHR vendors, such as Google Health and Microsoft HealthVault, are not subject to the strict privacy and security rules of the Health Insurance Portability and Accountability Act (HIPAA) because they are not "covered entities" (McCarthy, 2010).

This is not as much of an issue for hospitals because the records stay with the facility, but for a clinic this can be a very large factor in whether certain systems are implemented or not. Another issue that is akin to this one in legal circles is the question of who owns the data in a health record (Evans, 2011). Since there has been little legal wrangling over this particular topic, hospital's may claim that the information is proprietary and not release it even if the patient requests it.

Advantages

Fortunately, there are far more advantages than disadvantages. One of the first that doctors need to realize is that the electronic brain does not take the decision-making out of the professional's hands (Shay, 2009). The chart is the same as a paper chart except for the fact that it can access, instantly, a lot more information than a paper chart could. "Eventually the goal is to have a single medical record for each patient-one that is accessible anywhere, anytime, across the continuum of care" (Robles, 2009). This single chart will be able to be accessed by any authorized healthcare provider, and it does not matter if the person has seen a physician or been to a hospital in an extended period of time. This will eliminate the need to look through a multitude of old paper records to find one patients history.

A second advantage has to do with patient accessibility of the record. In the past, the data control issue would often cause hospitals or clinics to believe that the information was proprietary. Now, legally, that is not the case in many states. The move to EMR gives the patient and the provider;

"Enhanced patient safety and the ability to document and quantify improved outcomes. The push for quality and performance improvement is important not only for health care facilities but also for third party payers, both private and governmental. Many states are now requiring hospitals to publish their performance data online, arming patients with information to help them choose where they want to spend their health care dollars (Robles, 2009).

This is important because the courts have realized that personal control of sensitive information is paramount. Although there is not Constitutional guarantee of privacy, the privacy of medical records is an important factor in recent healthcare law.

The use of EMR makes the nurse's job easier in the whole even if the individual is not initially comfortable with the format. Robles (2009) lists other advantages that prove the efficacy of the systems regardless the reluctance of some individuals to accept it. Namely,

"In addition to increased availability of patient information, major benefits of the EMR include improved billing accuracy, improved interdisciplinary communication resulting in improved continuity of care, evidence-based decision support, improved documentation, enhanced legibility, reduced duplication, and improved speed with which orders are implemented. There are real opportunities for automating, structuring, and streamlining clinical workflow."

Nurses want to go home on time and this means that they have to be able to make report to the next shift in an efficient manner. EMR helps both the outgoing and oncoming shift make a more seamless transition. It does not matter if the previous nurse charted efficiently or not because the activities of the shift can be read from the EMR rather than having to rely on another person's memory.

Another issue is ease of use because the individual has to be sure that they can get the information that is needed without a great deal of hassle. This all comes down to testing the various systems to see which one works the best for that particular group of people (Pinto, 2006). If the nurses and doctors (and whoever else will utilize the system) are not comfortable with it, then it is a failed system. The advantage here over paper is that the systems are getting much easier to use, and charting on computer makes it easier to edit the document, and access other tools that may be needed for its completion.

Nursing role in implementing and utilizing EMR

Nurses have a pivotal role in the selection, implementation and use of EMR technology whether it is to be used in a clinic or hospital setting. The reason for this is that nurses will be the primary users of the technology. Implementation of a technology can have good and bad results just like the technology itself. The nursing staff needs to understand what they require of the system before they can be effective advocates for a particular EMR type. "A successful EMR implementation depends on an organization's infrastructure" (Bernd & Fine, 2011). The clinic or hospital must have a mission and vision that is compatible EMR system because there are differences in how they operate. There are also some "maxims" that must be followed during the implementation of the new system. They are: "A successful implementation depends on great planning and great execution; When profound change is involved, disruption should be anticipated; and Comprehensive EMR implementation is only possible through strong, clear leadership" (Bernd & fine, 2011). However, there are some pitfalls that can be avoided if the planning phase goes the way it should. One should "Never Underestimate a Good Support System," realize that "Real time and role-based support is critical to a successful launch," and "Success can be measured in quality and efficiency" (Bernd & Fine, 2011). All of these factors should be used to make sure that the proper system is installed and that all of the nursing staff that are going to use it are comfortable with the one being installed.

Bedside nursing streamlined with EMR

It does not take long to understand one of the major benefits of EMR implementation to both the nursing staff and the patients in a hospital. Hospitals are largely understaffed and nurses are overworked with all the responsibilities that they have. This means that something has to suffer, and it is usually direct, patient contact. Many say that they got into nursing because it was a way that they could interact positively with people, but that aspect of nursing is fading (Thede, 2008).

Because this is an issue that many see, nurses are generally excited when they start using a new EMR method. Actual bedside care is streamlined so that the nurse is able to spend more time with the patient than previously. So much time is taken up in accurately charting that the nurse often has to leave the patient and do this vital chore. With the advent of EMR, the nurse still has to chart, but he or she is able to access all of the records needed on one tablet, and write the charts much more quickly. Many EMR systems have templates for charting that make the whole process much easier.

Template documentation in EMR vs. free text documentation

However, there is a discussion about whether the template-type of charting restricts the nurse too much. Some believe that the template method is much easier because it takes away some of the thinking aspect and makes it more automatic. But, some nurses enjoy the freedom of "free text" documentation. It is basically a preference and most systems will allow a nurse to document either way.

JCACHO Guidelines for EMR Charting and Documentation

Regardless the type of charting that a nurse does he or she must still follow the guidelines that have been imposed. The JCACHO (now simply called The Joint Commission or TJC) is an organization which accredits hospitals and other healthcare organizations. This is important because it is necessary to have a singular body that sets standards and has responsibility for the maintenance of such. TJC has become so recognized that it is often necessary for a healthcare organization to maintain its certification to stay in business. The mission statement is "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value" (TJC, 2012).

Institutions Using EMR

TJC works with all types of healthcare clinics to endure the standards that they are setting. This means that there is continuity across the board in these organizations. Among these are places such as local pharmacies, doctors clinics and others that use various forms of EMR (EPIC, VISTA, and others). VISTA is the accepted EMR used by all government clinics in the United States (Rowley, 2010), but the most popular is EPIC (Kelsey-Sebold Clinic, 2009). Because of its ease of use, and the standard features that are much easier for a clinic setting, it is the most accepted form of EMR among clinics. The primary reason for this systems use is that it "facilitates ease of consultation and care coordination" (Kelsey-Sebold Clinic, 2009). It can be used across a large system, and has the power to maintain millions of records and billions of pieces of vital information.