Shawn Stewart, RN, CCMThomas Edison State College

August 24, 2008Dr Donna Bailey

The purpose of this presentation is to provide nurses with a comprehensive understanding of the Electronic Health Record (EHR), including:

Defining the EHR The Institute of Medicine’s Five Core Competencies Anticipating Clinical Benefits and Obstacles Recommendations for EHR Preparation

An electronic health record is an instrument that replaces traditional paper documentation with the use of computerized charting systems that interface with other departments.

Maintains lifetime information about an individual’s healthcare.

Provides complete, accurate patient data, regardless of the location of the patient.

Delivering Patient-Centered Care

Working as Part of an Interdisciplinary Team

Practicing Evidence-Based Medicine

Focusing on Quality Improvement

Using Information Technology

EHR Nursing Tools:

Decision Support

Clinical Reminders and Alerts

Links to helpful professional resources.

Improved Accuracy and Legibility of Documentation

Implementation of Standard Nursing Language

Increased Accessibility of Medical Record

Increased Time for Bedside Nursing

Prompts for Evidence-Based Interventions

Eliminate Duplicate Charting

Real-Time Information

Ability for Multiple Users to Access Simultaneously

Ease of Communication within Multidisciplinary Team

Decreased Time Charting:Automated Population of Vital SignsCheck Box AssessmentsCare Plan Templates

Order Entry:

Due to the utilization of electronic order entry accuracy of medication orders will increase. This will result in subsequent increases in quality and patient safety.

Improved Ability to Track Clinical Outcomes

Ease of Gathering and Comparing Statistical Quality Data

Enhanced Ability to Perform Timely Data Analysis on a Global Scale for Research Purposes

Adapting to Change / Resistance

Learning Curve

Intra-Facility Computer Literacy Initiatives

System Downtimes

Transition Period Frustrations

System Downtimes

There will be times when the EHR is down and the nurse will have to utilize the facility contingency policy. This could cause frustration and resistance to the EHR.

System Security Issues

Funding Allocation

Maintaining Confidentiality

Designated Resources:Overhaul of Policies and Procedures

Development of Implementation Plan

Staff Education and Training

Develop a task force or committee within your organization to identify anticipated barriers.

Utilize this team to create action plans specific to your team’s needs in preparing for implementation of the EHR.

Utilize forums such as Town Hall Meetings with administration & departmental meetings to inquire about the facility’s plan for an EHR.

Is there a nursing informatics position within your organization? Find out what resources are available.

Above all – Anticipate the direction in which documentation is changing. Be sure that you are ready!

Individual Skill Development: Taking a Computer Class or Learning to Type.

American Nurses Association (2008). Nursing informatics: Scope and standards of practice. Retrieved August 18, 2008, from http://nursingworld.org/books/pdesecr.cfm?CNum=3.

Glaser, J. (2007, October). The electronic health record: A digital divide? Retrieved August 21, 2008, from CINAHL database.

Health Professions Education: A Bridge to Quality. (n.d.). Retrieved August 23, 2008, from http://www.nap.edu/openbook.php?record_id=10681&page=1.

Pomerleau, M. (2008, April/May 2008). Electronic health record: Are you ready for the next step? Nursing for Women’s Health, 12(2), 151-156.

Selenke, J. (2007, December). EHR Bliss. Health Management Technology, 38-39.

Thede, L.Q. (2003). Informatics and nursing opportunities & challenges (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.