Electronic Health Records
Nursing Evaluation of Electronic Documentation Systems
Nurses are the end-users of many electronic documentation systems. The article provides an outline process for nurses to evaluate a computerized health record.
Nursing Evaluation of Electronic Health Records
Gone are the days when the phrase “computer skills” was a rare and wonderful addition to a nurse’s resume. Computer skills are now mandatory. Indeed, many nurses receive at least a portion of their nursing education by taking on-line courses. Nurses can now achieve a degree, or certification, in the Nursing Informatics specialty.
As many health care systems convert paper documentation to electronic health record (EHR) systems, nurses play an important role in the evaluation of these computer systems. These systems may also be called Electronic Medical Records (EMR), electronic documentation systems, computerized documentation systems, or computerized medical records. All refer to a form of health care technology to document the clients health care in an electronic format.
Nurses will be called upon with increasing frequency to evaluate the human component of EHR systems, as well as the effects of electronic documentation on clinical care. Easy access to client information is a primary goal for any electronic health record system. Three factors are important for the nurse to remember when asked to assist with the evaluation of an electronic health care documentation system. They are:
1. Is the system user-friendly?
2. Does the format of the system make sense to the clinician?
3. Is the system designed well for clinical documentation?
Is the EHR system easy to use?
Clinical documentation systems must be developed with the user in mind. In many cases, the nurse is the main user of electronic health records. Clinical staff should not have to struggle with documentation methods. The system should not be cumbersome, or require multiple or complex steps, in order to document basic client information.
Does the format of the EHR system make sense to the clinical user?
Electronic documentation systems may be designed by people with technical skills. What makes sense to a computer technician because it works technologically may be unusable to a clinician. Nurses are increasingly more comfortable with complicated equipment that is used to care for clients.
Equipment such as monitors, ventilators, pumps and other devices are used daily in hospital and other clinical settings. Most nurses won’t have problems learning to use a computerized record, but the format needs to make sense to the person giving and recording that care. The record needs to be formatted in a way that complements the nursing work flow.
Is the documentation system well-designed?
Good question! What is well-designed for a computer programmer or systems analyst may not be the same as well-designed for a nurse. There needs to be collaboration between program designers and the clinical staff who are the end-users of the product.
Employees usually receive detailed training in how to use an information system, but sometimes that training is the first actual evaluation by clinical users. If training is required to teach clinicians how to get around their usual work flow in order to use the system, efficiency will be decreased. It is important for nurses to be involved in the design of a clinical documentation program.
An electronic health record is used to document the clinical care given to clients as well as health care information about clients. It also provides a method of communication between providers of care. It can be used as a financial record, and can also be used in legal matters.
Advantages of an Electronic Health Record:
- Multiple health care providers can access the same information
- Information can be accessed remotely to improve care to the client
- Specific protocols can be programmed into the system and they can be based on the condition and problems of the client
- Protocols will often help to improve consistency of care, and adherence to clinical practice guidelines
- Repetition is generally reduced
- Information is stored, and not likely to be lost
- Can improve communication between health care providers
Disadvantages of an Electronic Health Record:
- Electronic documentation systems are expensive
- Employee acceptance and adaptation can be a challenging
- Systems can be confusing and time-consuming
Simply taking a paper record system and converting it into a computer is not considered an Electronic Health Record. The entire process must sometimes be redesigned. Systems strive to incorporate clinical standards of care and protocols into the documentation work flow in order to improve efficiency, as well as care. Information technology touches every aspect of health care. Nurses need to be actively involved in the design and evaluation of electronic records to assure that clients receive quality care.
Catalano, J. T. (2006). Nursing Now! Today’s Issues, Tomorrow’s Trends (fourth Ed.) Philadelphia: F. A. Davis.
