Electronic Health Records
Electronic health records systems are used in various hospitals, community health settings, and doctor’s offices to enter and view client information. Unique client identifiers are used to ensure that information about the client is linked with the correct health care provider, the client’s most recent results of laboratory and diagnostic tests, and an updated list of currently prescribed medications. Information about the client’s vaccination history, allergies, consults, operative reports, and discharge information is also provided. A benefit of using electronic health records is that health care providers have quick access to medical information. Clients benefit as they receive improved management of chronic diseases, such as when health care professionals can receive reminders of follow-up tests. Electronic health records also reduce unnecessary repetition of laboratory and diagnostic testing, which ultimately saves money. A risk of electronic health records is that people not within the circle of care may access confidential information. Regional health authorities have taken measures to monitor for such risks. These measures include providing limited access and monitoring who is viewing any confidential health information.
Electronic health records may also include the use of standardized evidenced-based protocols for nursing care. Nurses can access the most current evidenced-based protocol to see potential nursing interventions, which can serve to improve documentation of assessments and interventions by providing reminders to chart specific symptoms or to chart the administration of PRN medications.
Electronic health systems use standardized clinical terminologies so that all health care providers can communicate findings and share client information within their specific practice settings. Standardized clinical terminologies refer to a set of common terms that describe health conditions, treatment plans, and necessary interventions. Two examples of commonly used standardized clinical terminologies include the Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT)and Canadian Health Outcomes for Better Information and Care (C-HOBIC). Standardized clinical terminologies facilitate the measuring and recording of nursing care and data in a way that can be understood by other health care providers. Monitoring the length of time it takes to perform a nursing procedure is an example of recorded data that can then be used to help organize care. This recorded data can also be used to describe specific nursing activities, and their impact on client outcomes, including the client’s progression toward discharge.
Benefits of Standardized Clinical Terminologies for Nursing
Nursing practice guidelines, developed by the Registered Nurses’ Association of Ontario, are based on the results of systematic reviews, an expert panel, and stakeholder review. These nursing practice guidelines can be embedded electronically into any nursing plan of care to reduce variation in care based on a specific medical condition. By using a common terminology and following a specific plan of action, researchers will be more effective in using the information and comparing results with other information globally. These nursing interventions can then be described and understood by other health care providers as the client transitions from the hospital to community or home setting.
From the Field
It is important to maintain client confidentiality and follow the policies of workplace and regulatory bodies when using information and communication technologies.
Essential Learning Activity 14.2.1
Read Canada Health Infoway’s webpage about Electronic Health Records, then answer the following questions:
- Explain why digital records need to be available to all authorized health care providers.
- What are the challenges to and solutions for providing a comprehensive framework for sharing health information across the country?
- The 2016 Digital Health Blueprint identified ten computing environments. What are they?
- When determining how to implement a particular digital health solution, designers have many decisions to make. List three of these decisions.