Nurses Guide to Electronic Health Records

© 2006, Minnesota Nurses Association

Background/Introduction

A resolution addressing Electronic Health Records passed the MNA House of Delegates in 2005 highlighting the need for more information and strategies for nurses on this issue (attached Resolution: Electronic Health Record, MNA, 2005)

The impetus for electronic health records (EHR), like many information-technology (IT) solutions, has been fueled by recent reports (Institute of Medicine, Robert Wood Johnson Foundation, U.S. General Accounting Office, the U.S Department of Health and Human Services) on the failures of health care systems to maintain patient safety.  Reimbursement systems (Medicare, Medicaid, private insurers) are requiring an electronic health record as a condition of participation.  EHR has been identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients’ health histories and as a secure method of providing more informed clinical decision-making.

EHR has also been promoted as a mechanism for transforming nursing care, enabling nurses to function as “knowledge workers” with the potential of making nursing care less stressful, more satisfying, more research-based, and more visible (Simpson, 2005).

Even though EHR has been advanced as a mechanism for decreasing errors, it may slow the process of delivery of care and create unintentional negative effects if not properly evaluated prior to purchase and implementation. Moreover, IT solutions intended for the nursing staff aren’t often selected by nurses who will be using the systems.  Rather, the IT staff evaluates these applications and makes the final selections, often based on technology rather than clinical considerations (Kremsdorf 2006).  Nurses input should be sought early and often throughout the process of selection, implementation, and evaluation.

Healthcare has been much slower than other industries in adopting IT.  For nurses, this effect is compounded by the fact that there are few nurses prepared in the nursing specialty of informatics blending nursing, information, and computer sciences (Scope and Standards of Nursing InformaticsPractice, ANA, 2001).  Consequently, the technology and nursing perspectives essentially utilize different languages in their communication and may not even know the questions to ask each other.

Purposes/Functions of EHR

  • Health information and data processing for the purpose of clinical decision-making which includes evidence-based practice (EBP) and critical thinking.
  • Documentation of care consistent with legal and accreditation requirements.
  • Aggregating data for the purposes of quality assurance and research.
  • Tracking patient support systems and outcomes including flow of patient populations.
  • Administrative processing and reporting for budgeting, billing, and financial results management.
  • Interoperability for communication and connection across disciplines/departments/care providers/institutions, and geographical locations.

Nursing Principles

The knowledge work of nurses is complex, non-repetitive, and non-routine, consuming considerable levels of cognitive activity.  Nurses and other health care providers often receive a lot of data and information that may or may not be relevant to this cognitive work.  Unless the data can be easily translated into knowledge nurses can utilize in their practice, additional technology and more information may be merely another distraction in the already challenging, compressed work environments of nurses.  This is why it is important for nurses to be involved early and often.

The registered nurse is responsible and accountable for her/his documentation according to professional practice standards (Code of Ethics for Nurses with InterpretativeStatements, ANA, 2001; Nursing:  Scope and Standards of Practice, ANA, 2004; MN Nurse Practice Laws and Rules, 2003).

The following principles apply to Electronic Health Records:  (Excerpted from the ANA document, Principles of Documentation, 2005)

  1. Must assure unique patient ID.
  2. Must assure unique provider ID.
  3. Must assure security and confidentiality.
  4. Must be accurate, clear and complete, timely, and retrievable.
  5. Must meet existing standards promulgated by regulatory agencies, eg HIPAA,
    CMS and accrediting organizations such as JCAHO.
  6. Must be legible, complete and authenticated by the responsible persons for ordering, providing, and evaluating the care.
  7. Abbreviations, acronyms, and symbols must be standardized.
  8. Must include organizational policies/procedures related to documentation.
  9. Must include a standardized/recognized nursing terminology that specifies the domain of nursing (attached, A Common Unified Structure For Nursing Language, 2003) so that data can be aggregated and measured.

Essential Nursing Information

In addition to connection to the general nursing process of assessment, plan of care, implementation, and evaluation, the following specific information needs to be included:

The appropriate title of a nurse/health care provider(including specifying RN, LPN, for nurses).

  • Medication management
  • Medical treatments/outcomes
  • Pain assessment and management
  • Risk factors and interventions
  • Delirium assessment and interventions
  • Psychosocial information
  • Patient/family knowledge of condition
  • Patient/family teaching/outcomes
  • Information about care across the continuum, internal (eg ED, ICU) and external (assisted living, nursing home, home care, etc)

Advanced Health Care Directives

Recommended Questions for Nurses to ask in Considering the Selection of a System

  1. Usability:  Is the system being implemented efficient and effective? What is the ease of learning and using?  Is the nature of errors (eg types, severity, circumstances) being tracked during the various phases of the system applicability?  How will errors be handled?  (For the purpose of identifying system issues rather than personal performance or discipline.)
  2. Focus:  Is the system patient-centered?  Is it consistent with the model of nursing practice being utilized by the facility?  How will the staffing system (both short and long term) be altered during the implementation of the system so that the process of implementation does not affect the nurse’s ability to protect patient safety?  Does the system facilitate intrapersonal communication among the multidisciplinary team members?
  3. Barriers:  What are the time constraints for nurses eg short-staffing?  Are the resources/research materials easily accessible?  Has adequate formalized training on the specific technology been conducted?  What is the educational preparation for nurses on technology based on their roles?  Have all health care providers been given basic computer instruction?  Have point of care nurses been involved in the selection, planning, implementation, and evaluation of the system?  Have the vendors described the evolution of this system, e.g., Has the system been designed for this type of setting?  How it was developed?  Who was it designed for?  What continuing support do vendors and others provide, e.g., Is assistance available 24/7?
  4. Legal issues:  How are the system and users meeting their legal obligations under HIPAA and other relevant state and federal laws?  What is the RN liable for if data is missing or misentered that causes errors?  Is there a cross-check of data for provider order entry?  Are the licensed nurses and other health professionals clearly identified by title and able to practice and document within their scope of practice?  Are all persons responsible for patient care concerns of the EHR a qualified nurse appropriately licensed to practice, be delegated to, or delegate?  Is there an oversight of the data entry and data release by a variety of disciplines?  Of the persons who can view the record, is access for entering and editing notes controlled?  What is the level of security of information in the record?
  5. Ethical issues:  Are confidentiality, security, privacy, and informed consent protected?  Is a code of ethics mandated by every health profession integrated and balanced with common corporate business practices?  Is there a potential conflict of interest with a particular company’s marketing strategy?  What is the system capable of regarding consumer access?
  6. Integrity:  Is there assurance that essential information is comprehensive, accurate, and available when and where it is needed?  What is the trustworthiness of the data?  e.g., Is it secure, confidential and available only to those providers needing the information for patient care?
  7. Ergonomics:  Have the attributes and characteristics of physical workstations and equipment been evaluated and addressed appropriately?  Have workflow issues been considered including frequency and usual duration of data access/entry and adequate number of computers?  Will nurses be able to access the information in a timely manner so as not to disrupt work flow?

Recommendations 

(From Principles of Documentation, ANA, 2005)

  1. Nurses should participate in the decision-making, design, testing, and evaluation of documentation processes and information systems.  (“Use-cases” to describe how the system will work for nurses specifically need to be developed. 
  2. e.g., Is nursing involved in “test” cases to see if it holds up to actual nursing practice?)
  3. Documentation processes and information systems should be designed to promote the concept of “record once, read many times.”
  4. Data sets composed of ANA-recognized terminologies should be utilized in the nursing documentation of these processes, assessments, identification of clinical problems or nursing diagnoses, nursing interventions, and nursing-sensitive outcomes.  How nurses “talk” to these references/terminologies needs to be clear and concise (sample attached,"Taxonomy of Nursing Practice: A Common Unified Structure For Nursing Language").
  5. In interdisciplinary care systems, nursing-specific documentation should be recorded in a format that makes nursing data retrievable, reusable, and able to support data aggregation and analysis.
  6. Professional nurses have the right and responsibility to critically evaluate references to standards and documentation expectations in alignment with ANA’s Principles for Documentation when documentation processes, policies, or procedures are developed or modified within their organizations.
  7. The type and numbers of equipment for electronic health records should be consistent with the normal workflow and the frequency and usual duration of data entry and data access.
  8. Equipment should be installed in locations and in such a manner as to eliminate and/or minimize ergonomic hazards for the users of the equipment.

Glossary of Terms

  • Nursing informatics is a blend of nursing science, information science and computer science to manage and process nursing data, information and knowledge to facilitate the delivery of health care.
  • Clinical decision-making is a process of choosing among alternatives.  Nurses are usually involved in an array of decisions, often involving a cluster of issues rather than single decisions. Nurses make numerous decisions that affect the life and well-being of individuals, families, and communities.
  • Knowledge work is non-repetitive, non-routine work consuming considerable levels of cognitive activity.
  • Critical thinking is the intellectually disciplined process of actively and skillfully using knowledge to conceptualize, apply, analyze, synthesize and/or evaluate data and information as a guide to belief and action.

References

  • ANA, Code of Ethics for Nurses with Interpretative Statements, 2001
  • ANA, Principles for Documentation, 2005  (Copy available on member only web site –www.ana.org)
  • ANA Recognized Terminologies and Data Element Sets, 2005 (www.nursingworld.org/npii/terminologies.htm)
  • ANA, Scope and Standards of Nursing Informatics Practice, 2001
  • Henderson, V. The Essence of Nursing in High Technology.  Nurs Admin Q. 1985; 9(4)
  • Institute of Medicine, Key Capabilities of an Electronic Health Record System, 2003 (www.iom.edu)
  • Kremsdorf, R. Part I – Failure to Rescue and Errors of Omission. Patient Safety and Quality Health Care. 2005 2(4).
  • Kremsdorf, R. Part III – Building a Comprehensive Safety Net, Patient Safety and Quality Health Care. 2006 3(1).
  • MN Nurse Practice Laws and Rules, 2003
  • Morrissey, J.  A Day in the Life of a Medical Record, National Alliance for Health Information Technology
  • Simpson, RI.  From Tele-ed to Telehealth:  The Need for IT Ubiquity in Nursing. Nurs Admin Q. 2005; 29(4)

Reviewed and approved by the Commission on Nursing Practice, July 12, 2006
Accepted by the MNA Board of Directors, July 27, 2006

345 Randolph Avenue, Ste. 200, St. Paul, MN 55102 | Telephone: 651.414.2800 | Toll Free: 800.536.4662 | Sitemap