Electronic Health Record Implementation, Research Paper Example

Introduction

Medical science is developing everyday and nurses need fast access to up to date information to treat patients. The traditional method of handwriting medical record has proven to be inaccurate and insufficient time after time. Traditional handwriting of medical records has caused many apparent problems. First, many mistakes have been made because the written notes could not be read and comprehended by the intended receiver due to illegible handwriting. It’s no secret that many nurses may see a hundred or more patients in one day. So, it is very possible that throughout the day their handwriting may become less legible.  Secondly, storing and saving paper records is very difficult. Overtime paper may become worn or faded with use making information illegible. Paper records can also prove difficult to share between nurses and other medical service providers. In the United States alone, more than 50,000 deaths per year are directly correlated to medical errors (Ash, et al, 2003). Implementing electronic health records can be a great way to enhance the services that  health care providers provide to clients by ensuring that patients are receiving the best care possible with lesser likelihood of errors.

Implementation

People in healthcare are facing great challenges while trying to implement electronic health records. Many of these challenges are legal in nature. Because technology is new in the field of healthcare, there are few precedent scenarios that guide decisions. One major problem is determining if nurses are responsible when health records have been illegally viewed and/or transmitted. Many nurses are leery about this issue because they do not want to be liable for computerized documents. Many feel more comfortable with information being under lock and key. However, when choosing the right program for an organization, nurses can chose systems that provide the same kind of security. Some programs require codes to view or transmit medical records. So, each time someone views or transmits data he/she is identified by a specific code. This is actually more secure than lock and key because the nurses can now identify who has viewed data, how many times they have viewed, and even how long the particular file remained opened.  According to Lorenzi (2000), to successfully implement electronic health records system, the organization has to be willing to make the needed changes. These changes will include changes in management. He also believes that outlining and taking a closer look at what may have caused other organizations to fail in their implementation of the systems. By doing this, they will be able to overt possible problems and optimize the use of a new effective system. When this is done correctly he says the organization has created “cornerstone for developing a new information management paradigm for health care” (2000).

Proper implementation will require willingness from all stakeholders.

Cost has also been a major issue in implementation of electronic health records. It is estimated to cost between 50 and 60,000 dollars to properly install electronic health records. (Booz, 2009). However, the government has offered some stimulus packages to help offset the cost of total implementation. Nevertheless, those nurses who operate private facilities are not eligible to receive those benefits. One reason that nurses are implementing electronic health records is because the time for maintaining records on a patient has increased to 7 years. The 7 years are calculated from the last time the patient sees the nurses.

Privacy Issues

The use of electronic health records has raised some questions about privacy. Patients and nurses have concerns about medical data being viewed by someone who has not been given permission to do so. Recently, there have been issues with nurses having their entire medical history programs hacked by thieves. In 2009 alone, more than 1 million people were victims of medical identity theft (Booz, 2009). As a result, many patients have opted out of having the medical data stored and transmitted electronically. According to hung, more than 10 percent of identity theft victims have been misdiagnosed and another 15 percent were prescribed the wrong medication in the wake of an identity theft issue(2005).  Nevertheless, some nurses are not willing to maintain paper records and electronic records too. In the age of technology, medical identity theft has risen drastically in the past 10 years. Both personal and medical identity theft are horrid, but medical identity theft can lead to the death of the victim.

The Benefits of EHR

Patients and nurses both believe that implementing electronic health records is a great asset. The pros greatly outweigh the cons. Proper implementation of electronic health records ensures that the patient will receive improved coordinated care. The quality and service of the nurses’ care will improve because electronic health records will speed up diagnosis and communication between multiple stakeholders. According to the article, A Technological Approach to Enhancing Patient Safety, when modern technology and efficient clinical work are combined, the reduction of medical errors and malpractice are drastically reduced. The article stated that more 12-15 percent of costs that hospitals incur are due to medical errors. The largest category of medical errors fall under the adverse drug affects. When nurses use this system, they can ensure that they are aware of all medications a patient may be taking before prescribing another (HIMSS, Chicago, IL, USA).With this system, nurses will have accurate information at their finger tips. The most important benefit of electronic health records is the fact that nurses will be alerted if there is a medical conflict for a patient. Many patients have more than one nurse. Most times, one nurse is not aware of what has been prescribed by another nurse. This lack of communication can lead to a deadly outcome. Electronic health records will eliminate this issue.  Patients often complain of billing errors. Electronic health records can also help to eliminate this problem. One study conducted concluded that electronic health records reduced billing errors by more than 60 percent. With electronic health records coordinated care is made possible. This is very important for the patient. In that same study it was found that more than 85 percent of those survey believed that electronic health records are beneficial to both the nurses and patient (Layman, 2008).

Our Facility

Before we implemented electronic health records we did a survey to determine if it would benefit us or not. We first sought to determine if our administrative process was organized and efficient through the use of proper documentation. Next, we wanted to know if the daily workflow was efficient and organized and that all staff understood what they needed to do. Once that was determined, we looked at how implementing electronic health records would change the process. All stakeholders agreed that electronic health records would help our organization. We selected a leadership team to spearhead the process. All members of the staff were trained in the proper operation of the system and we hired a technology specialist to remain onsite during the early stages of the implementation. The specialist would walk staff through the daily process. After the beginning stages were over and it was felt that all members were ready to go unassisted, we did our first day without tech support. We have found that daily processes are more efficient and faster.

Conclusion

Electronic health records are an innovative way for nurses to have access to medical records that are easily accessed and accurate. This ensures that patients are receiving the best services possible from their medical provider.  Consequently, the implementation of electronic health records provides great benefits to both nurses and patients. For nurses, it lessens the probability of being sued for malpractice, and for patients is lessons the probability of faulty diagnosis and being prescribed the wrong medication.  In the long run, these services will offset the costs that nurses are facing in maintain paper medical records. The implementation of electronic health records may not be an easy process, but with cooperation from all parties the process can be a success.

References

Ash, J S., Z Stavri, & Gilad J. Kuperman( 2003). A Consensus Statement on Considerations for a Successful CPOE Implementation. Journal of the American Medical Informatics Association 10(3) 229-34.

Booz, A. H.  (2009). Medical identity theft final report. U.S. Department of Health and Human Services.

Layman, E. (2008). Ethical issues and the electronic health record. The Health Care Manager, (27) 2. 165-167.

Lorenzi, N. M(2000). The Cornerstones of Medical Informatics. Journal of the American Medical Informatics Association 7(2), 204.