NUR3020 Measuring Electronic Health Record Use in Primary Care: A Scoping Review

 

Introduction

In health care, maintaining electronic records is vital to ensure all aspects of patient care including efficiency, safety, time, and integrating patient information for better decision making and efficient care.  All healthcare organizations need to have a policy and procedure to maintain and secure health records of the patient and other tasks electronically to avoid the risk of data loss and breach of confidentiality. In this essay, we are going to discuss the importance of using digital health records in the health care setting and the responsibility related to documentation of the records. In end, a conclusion relevant to it will be given.

Personal and Professional Self Reflection

In health care, health record offer secure information of an individual such as medical history, health summary, referral, prescription, discharge summary, etc. which I believe is vital to deliver more efficient patient-centered care. Basically, I think this platform gives us the opportunity to look at the information in formats that were not easy with registers.  It is been showed that electronic health record can help in the management and prevention of chronic disease (Su & Yude, 2012).  This method help nurses to be aware of goal and alerts when providing care. The structured data of electronic health records provide possible access to valuable data to practice and conduct research. This medium will also help in organizing and accessing the data systematically and help in avoiding the risk of ambiguity. Also, electronic health record will improve communication with the patient and their families as this format provide structured information and clear prescription which help in avoiding medical errors in prescribing.  I believe that this format makes us book appointments easily, and it is very effective in collaborating with the patient who lives remotely. In present, many organization uses the electronic health record to improve health surveillance and effective decision making.  Also, I believe that the electronic health record system is an important primary clinical care that works compassionately to improve the health of the patient. As in today's time, everything is going digital this platform is easily accessible to share their health query more effectively so that more effective care plans can be made to meet patient needs. This is a powerful tool to improve health care but in order to attain its benefits it is heavily dependent on the way the system is optimized, and I am aware its development will bring vital organization, security, and ethical challenges that needed to be considered. Also, some simple processes maybe complex electronically, such attaining consent by signing the paper/letter which now has to be done by scanning or attaching or signing via signature pad. Assimilated database analysis permits graphing health trends and reconciling medications (King, Patel, Jamoom & Furukawa, 2014). In order to find important information easily electronic health records must be able to categorize data systematically, such as a scanned document. Also transferring checks may be challenging through electron health records may be challenging considering initial system design. Also, electronic healthcare records may contain many communication channels among healthcare professional thus, I think it is vital that organizations come up with the procedure and inform employees about the channels clearly to avoid failure of communication.    I think it is my responsibility to utilize this technology in an obligation to policy and procedure to deliver effective patient-centered care, as this will help in accessing and sharing health records with the patient in an effective way.

Evaluation

I feel that in today's time e-digital is a great platform to connect to services as per your requirement, this is an easier and quicker way to access the vital health records in obligation to organization-defined policy and procedure supporting effectively to avoid medical errors which are good thing about this experience. E-health is a platform that improves health care function efficiency and quality of patient-centered care, and without healthcare professional acceptance and utilization of the platform, the benefits of eHealth and electronic health records cannot be attained effectively (Hage, Roo, van Offernbeek & Boonstra, 2013). We can say that electronic health records have transformed the health industry and have many benefits such as patient-centeredness, communication, safety, and fairness. This platform help in patient engagement as patient permits take ownership of their care, the patient can easily receive and send message to the healthcare facility as per their need and can use their own devices to check the prescription, lab result, and suggestion on portal quickly (Ren, Deng, Hong & Zhang, 2019).  Also in case of disaster or data loss, the electronic health record is more secure compare to register and charts. The system will help nurses enter and access patient data immediately, but as we know in today’s time anyone can access data that is why it is vital to follow the state and federal policy and procedure to ensure patient confidentiality. There is some disadvantage too such as the risk of data breaches, as mentioned earlier it is vital for the organization to define the communication channel to nurses and procedure to assist the patient to avoid the ambiguity and medical errors.  In an electronic health record system, data breaching is one of the big issues but the organization and patient can mitigate the risk by installing secure firewalls and another security measure (Anderson, 2007).  I think there is one more disadvantage of the electronic health record that is patient access to all comments including negative ones as the patient might misunderstand the comment. It possible that the patient may misconstrue the comments that are not negative but the patient misunderstood because of not knowing the medical terminologies which are another disadvantage of the platform (Kim, Lee & Kim, 2018). Also, older patients might not know how to use this platform. Thus, it vital that both patient and healthcare staff get trained or educated about the platform through health campaigns or face-to-face meetings so that people can utilize this medium when needed.

Analysis

As we live in the digital era the electronic health care record or e-digital platform help in sharing and medical data quickly and attain the best medical assistance. Though with an effective plan in obligation to federal policies this platform has many benefits for both healthcare professionals and patients, we cannot deny the short-coming of the system whether it’s unsafe technology or unmet data.  It is been recognized that end-user information failed to reduce ambiguity which led to risk to patient health (Alpert, 2016). Another concern is related to the safety of the patient such as marinating the patient unique context, or its failure to support a particular task (Rametta & Freitas, 2017).  So we can say that with correct procedure and training and some modification this system benefits can be attained successfully. As I believe this technology is very useful for the healthcare professional who has much responsibility and manual way of documenting, monitoring and sharing data can be time-consuming, thus some alteration in software to ensure that patient consult the doctor without misunderstanding the medical terminologies or limitation to visible comments, and defined channel to access data will help health industry to work more efficiently using these technologies.  All the healthcare professionals to get training within organization to handle the platform, the training to documenting information and communicate with patient through this medium must help a lot, also educating the patient about the correct way to use it, can help in handling the situation competently.

Strategies for practice                    

As a registered nurse the first thing that can help in the situation is doing self-assessment which help in identifying my strength and weakness so that I can fill the gap to work more efficiently. Self-assessment helps healthcare professionals to deliver quality care without ambiguity (Kannan, Fish & Willett, 2016). Working in obligation to both organization and government policy always help in avoiding the breach, as we know that when handling the data related to the patient or sharing information with the patient it involved the risk of breaching patient confidentiality, thus, the supreme way to avoid breach is working as per set policy and procedure. Also, I will consult the senior staff in case of any ambiguity.  Using effective communication skills to ensure that patients understand what has been suggested, calling the patient to confirm the prescription and suggestion so that we can avoid the issue of patient misunderstanding the medical terms. I will take consent from the patient and the health organization before using the data related to the patient. As a registered nurse-patient safety and comfort is the top priority, therefore I will ensure that I use effective communication skills both verbal and non-verbal to educate the patient about the correct use of the system when sharing data, I will also ensure that utilize the platform correctly safeguarding individual personal information.  This system will give us the goal and procedure to certify that we provide quality patient-centered care through analysing structured data of electronic health records provide possible access to valuable data to practice and conduct research. This medium will also help in organizing and accessing the data systematically and help in avoiding the risk of ambiguity. Hence, I think with these modifications this platform will transform the health industry to provide care to people more compassionately and confidently.

 

Conclusion

The electronic health record is vital in the healthcare field to ensure quality patient care including efficiency, safety, and time.  This system allows us to look at the information easily and quickly, can also help nurses to be aware of goals, alerts, organizing and accessing data which help in avoiding ambiguity and medical errors. This platform help in patient engagement as patient permits take ownership of their care, though the electronic health record has some disadvantages like the misinterpretation of the medical term by patient and data breaches but with updated software, defined policy, and procedure and working ethically to ensure patient safety and comfort can help in attaining benefits of the e-health.

 

 

 

Reference

Alpert, J. S. (2016). The electronic medical record in 2016: Advantages and disadvantages. Digital Medicine, 2(2), 48.

Anderson, J. G. (2007). Social, ethical and legal barriers to e-health. International journal of medical informatics, 76(5-6), 480-483.

Hage, E., Roo, J. P., van Offenbeek, M. A., & Boonstra, A. (2013). Implementation factors and their effect on e-Health service adoption in rural communities: a systematic literature review. BMC health services research, 13(1), 19.

Kannan, V., Fish, J. C., & Willett, D. L. (2016, February). Agile model driven development of electronic health record-based specialty population registries. In 2016 IEEE-EMBS International Conference on Biomedical and Health Informatics (BHI) (pp. 465-468). IEEE.

Kim, H. S., Lee, S., & Kim, J. H. (2018). Real-world evidence versus randomized controlled trial: clinical research based on electronic medical records. Journal of Korean Medical Science, 33(34).

King, J., Patel, V., Jamoom, E. W., & Furukawa, M. F. (2014). Clinical benefits of electronic health record use: national findings. Health services research, 49(1pt2), 392-404.

Rametta, Z. M. D. J., & de Freitas, D. F. (2017). Health and administrative professionals perception regarding the patients Electronic Medical Record (EMR). International Journal of Development Research, 7(11), 17170-17174.

Ren, C., Deng, Z., Hong, Z., & Zhang, W. (2019). Health information in the digital age: an empirical study of the perceived benefits and costs of seeking and using health information from online sources. Health Information & Libraries Journal, 36(2), 153-167.

Su, C., & Yude, W. (2012, August). The care of the elderly with chronic disease based on electronic health records. In 2012 International Symposium on Information Technologies in Medicine and Education (Vol. 2, pp. 760-763). IEEE.

 

            

 

 

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