The electronic health record: An essential tool for advancing patient safety

Abstract

According to a recent American Hospital Association survey, 68% of US hospitals reported they had fully or partially implemented electronic health records in 2006. The adoption of the electronic health record has resulted in numerous improvements to support patient quality and safety. To be sure, the benefits from this technology are only beginning to be realized. Notable improvements have been identified in practice standardization, decision support, communication, and data capture for management, research, and quality monitoring. These advances—particularly in the integration of patient care standards, the creation of alerts for clinical interventions that are out-of-standard or incomplete, and data management systems—can be related to improvements in patient quality and safety. The electronic health record is now used by patients, caregivers, and researchers to achieve the following goals: ● Collaborate and clearly identify patient care needs, ● Document and communicate those needs to all team members in real time, ● Create an integrated plan of care, ● Integrate evidence-based clinical standards and evidence-based principles within documentation templates, ● Identify expected outcomes, and finally to ● Evaluate the processes and outcomes of care. While these goals of collaboration, communication, planning, integrating evidence-based standards, outcome management, and evaluation of processes and value are not new to healthcare professionals, they can now be more fully and realistically achieved with the electronic record. Three specific applications within the electronic record—computerized physician order entry (CPOE), electronic medication administration records (eMAR), and clinical documentation—are impacting patient safety in numerous ways by decreasing incorrect and unnecessary treatments and medications, as well as improving the timeliness of care. The benefits from these 3 applications vary, depending on the implementation sequence; some organizations implement each application as separate initiatives, while other organizations have implemented all 3 applications simultaneously.