Informatics: The Electronic Health Record: Will Nursing Be on Board When the Ship Leaves?

Abstract

Citation: Thede, L., (Aug 18, 2008) Electronic Health Record: Will Nursing Be on Board When the Ship Leaves? OJIN: The Online Journal of Issues in Nursing Vol. 13 No. 3. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Informatics/ElectronicHealthRecord.aspx You and your care team in the emergency room have just received an unconscious, air-flighted, car-accident victim. Yet even before she arrived, you had learned, in addition to the information about her new injuries provided by the paramedics and nurse aboard the helicopter, the name of her primary physician, the source of her insurance, that she was from a town 1,500 miles away, that her blood type was A positive, and that she was on an anticoagulant and had had a hip replacement six months ago after which she developed a deep vein thrombus. Sound far fetched? The technology to make this happen is with us today, and in some countries it is already a reality. The technology used in communicating the information in the scenario above included a healthcare smartcard and an electronic health record (See Table). Electronic health records are designed to provide nationwide access to designated information compiled from data found in medical records created by various providers regardless of whether providers are in the same healthcare system, or as in the case of the accident victim described above, in a different system far from the patient's home. You are probably already familiar with at least some components that will be included in an electronic health record. Your agency may already be using computerized provider order entry (CPOE), or have implemented other computerized systems, such as a medication administration system. These components are all building blocks for a complete agency record that is labeled the electronic medical record (EMR) (See Table) (National Alliance for Health Information Technology, 2008) that is owned by the provider that has created it. In contrast, an electronic health record (EHR) (See Table) is created when information from records created by a variety of agencies that are under different ownership is made available to other healthcare providers within a network. The EHR allows those healthcare providers designated by the patient to obtain healthcare information related to past episodes of healthcare. It is hoped that such a record will eventually be a birth-to-death electronic healthcare record. Sharing healthcare information between unrelated providers will probably start with the creation of a Regional Health Information Organization (RHIO) in which providers in the same area share information. This step involves the electronic exchange of health-related information between organizations in the same geographical area using agreed-upon standards, protocols, and other criteria (National Alliance for Health Information Technology, 2008). Eventually, the RHIOs will be combined into larger entities until all the healthcare providers are connected in a National Health Information Network (NHIN) throughout the United States. This network will provide access to patient-designated healthcare information for clinical decision making nationwide (United States Department of Health and Human Services, n.d.). As you can imagine, there are many technical issues involved in creating the NHIN, including data security, data access, patient identification, and the ability for all systems to communicate with one another. Information technology specialists are currently addressing these issues. Additional issues that will affect nursing even more directly are the types of nursing data that will be included in electronic health records, and the terminologies used to convey this data. In the past, and currently, nursing notes, unless used institutionally in infection control reports, quality improvement projects, or for legal issues, are filed upon patient discharge in medical records departments and then are generally ignored. …