Clinical Decision Support and Electronic Health Records in Nursing

Introduction

Information technology has revolutionized nearly every aspect of life, from how people recreate to how they work. This is no less true in the field of health care, where clinical informatics is reshaping the nursing workplace environment, how patient data is recorded and shared, and how health care is delivered. This paper discusses clinical informatics concepts emerging in the 21st century, what evidence-based practice (EBP) shows with respect to clinical informatics, how the law figures into this issue with respect to HIPAA, privacy, confidentiality, and security; and how patient safety, the nursing role, and electronic medical records are impacted.

Clinical Informatics Concepts in the 21st Century

Controlling the flow of information to promote efficiency, security, and safety is the number one priority of clinical informatics. Twenty-first century concepts for how this can be accomplished include training in how to find information, how to appraise information, and how to apply information. One common mistaken assumption among nurses is that having clinical informatics skills simply means having computer literacy (Khezri & Abdekhoda, 2019). While computer literacy is a necessary component, it is by no means the full concept of informatics.

In the 21st century, nurses need to know how to engage in information retrieval much as librarians do. They need to be able to enter information into databases, retrieve information from other databases, search for information, and manage knowledge effectively. Additionally, they have to be able to appraise information. When conducting an information search in a database, a nurse may receive thousands of different references or sources. If they cannot process and appraise that information effectively, the ability to conduct a search is of limited value. Thus, informatics is more than knowing how to use a computer or obtain information; it also encompasses how to appraise information and assess its value. Keeping complete records for electronic medical record (EMR) databases is likewise part of the concept, given the need for continuity of care, which necessarily depends upon continuity of information (Kleib & Nagle, 2018).

Database Systems, Analytics, and Nursing Research

Database systems require that nurses understand the concept of analytics as well. Nursing research is no different from any other kind of research in which data analysis is involved. Nurses must be able to search data, appraise it, compile the relevant findings, and utilize them for research purposes. Sousa, Reeder, Bondy, Ozkaynak, and Weiss (2017) note that even today nurse leaders do not have adequate access to EMR. Without adequate access to EMR, nurse leaders cannot engage in effective or timely decision-making (Sousa et al., 2017). Nursing research must focus more on how to positively integrate EMR systems into nurse workplaces. One of the key questions going forward is whether nurse PhDs, researchers, and leaders are being adequately prepared in the classroom to handle big data or data science (Westra et al., 2017). As technological advances continue, the need to handle, process, interact with, and command informational technology resources has grown—and nowhere is that more evident than in health care.

Informatics, EBP, and the Law

Nursing informatics can be useful when it comes to implementing EBP for quality care (Elsayed, Hussein, & Othman, 2017). However, as Effken, Weaver, Cochran, Androwich, and O'Brien (2016) point out, nurses tend to be data-rich yet information-poor—meaning they have as much data as they could want at their fingertips yet lack the skills to retrieve or make sense of that data. One EBP strategy to consider is the practice of mapping clinical terms to standardized terminologies to help nurses better understand how to use information (Effken et al., 2016). Elsayed et al. (2017) posit that informatics competency should be made part of the standard nursing curriculum in order to promote the use of EBP across the field.

Nursing informatics can also be used to promote health literacy among at-risk patients (Haupeltshofer, Egerer, & Seeling, 2020). By teaching older patients how to use technology to retrieve health information, nurses can increase access to health literature and foster health literacy. Technology thus carries advantages that can be used to encourage the EBP of promoting health literacy as a means of preventive medicine. Still, this requires an informatics competency that has not yet been standardized in nursing education.

Nurses using clinical informatics must still be careful, however, regarding how information is shared. The Privacy Act of 1974 regulates how information is collected by the federal government, which means nurses working in Veterans Affairs must follow these regulations. The Conditions for Coverage of Specialized Services by Suppliers—part of Medicare law—also requires that patient health information remain confidential and private. Patients must provide written authorization before their information can be shared or forwarded. Health care facilities must protect patient information, which is why EMR must be securely maintained—a challenge that numerous data breaches over the years have underscored.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was implemented to regulate how health care facilities handle health information, and HIPAA violations can lead to significant fines. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 likewise grants the Department of Health and Human Services authority to regulate the use of health IT and clinical informatics. Safety, security, and quality issues are all overseen by the federal government under HITECH.

Conclusion

Technology is changing the way health care is provided in the 21st century. Information technology, EMR, telehealth, and communications systems represent just some of the ways in which nursing is adapting. Collaborative care, continuity of care, and the reduction of nursing errors are among the ways technology can improve the nursing field. Telehealth allows time and geographic obstacles to be overcome, and patient quality of care can be improved as clinicians use EMR for clinical decision support. Patient data and patient safety must remain priorities, however, as patients have a right to know that their health information is protected at all times. Facilities that fail to protect patient data can be fined under HIPAA. Nurses play a major role in this regard, as they are end users of the technology and must safeguard passwords and remain alert to phishing schemes used to gain unauthorized system access. Technology thus offers a great deal of support for nurses in today's industry, but it also carries risks—from patient data being stolen to nurses' own health being burdened by alarm fatigue. Proper understanding of technology and its utility is essential.

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