Lecture Nursing documentation using electronic health records: Chapter 1 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 1 - An introduction to electronic health records. Chapter 1 content: Brief history of electronic health records (EHRs), history of standards development for the EHR and nursing’s role in their development, certification bodies for the EHR, benefits of the EHR, government involvement in the EHR, role of nursing informatics in healthcare.

1.3 Certification bodies for the EHR

1.4 Benefits of the EHR

1.5 Government involvement in the EHR

1.6 Role of nursing informatics in healthcare

L.O 1.1 The EHR History

L.O 1.1 The EHR History

• Impetus for development

– Quality patient care

• 1960s

– First EMR programs

– First electronic databases

L.O 1.1 The EHR History

• Terms and Definitions

– CPR: Computer-Based Patient Record

– EMR: Electronic Medical Record

– EHR: Electronic Health Record

– CCD: Continuity of Care Document

– PHR: Personal Health Record

L.O 1.1 The EHR History

• Point of care documentation

• Modes of Data Entry

L.O 1.1 The EHR History

• Security and reliability

– Local area network (LAN)

L.O 1.2 Development of EHR

Standards

• IOM’s Committee on Data Standards for

Patient Safety – 2003

– Identified key competencies

– Became foundational benchmark for EHR

development and programming

• Consolidated Health Informatics (CHI)

standards - 2004

– Enabled agencies to share information

– Common clinical vocabularies

– Standard methods of transmission

• Role of nursing in standards development

– Promotes standardization to identify nursing’s

contribution to patient care

– Promotes research

– Promotes identification of relationships among nursing interventions and outcomes

• Technology Informatics Guiding

Educational Reform (TIGER) Initiative

– Goal to ensure nursing input into the

standardization process for EHRs

– Calls for agreement on the standardized

nursing terminology to promote

interoperability

• Standardized nursing language examples

– NANDA-I, NOC, NIC

– ICNP

L.O 1.3 EHR Certification Agencies

L.O 1.3 EHR Certification Agencies

• The Certification Commission for Health

Information Technology (July 2004)

– Mission: To accelerate the adoption of health information technology by creating an

efficient, credible, and sustainable product certification program

• CCHIT

– Creates inspection process for:

• Ambulatory care EHRs for the office-based healthcare provider

• Inpatient EHRs for hospitals and health systems

• Network components through which EHRs interoperate and share information

• Office of the National Coordinator for

Health Information Technology (ONC) -

L.O 1.4 Benefits of The EHR

L.O 1.4 Benefits of The EHR

• Enhanced accessibility to clinical

information

• Patient safety

• Quality patient care

• Efficiency and savings

L.O 1.5 Government

Involvement in the EHR

in the EHR

• President George W Bush (2004)

– Called for universal EHRs by 2014

“By computerizing health records, we can avoid dangerous medical mistakes,

reduce costs, and improve care.”

in the EHR

• Medicare Improvements for Patients and

Providers Act of 2008 (MIPPA)

– Positive incentives for practitioners who use

in the EHR

• American Recovery and Reinvestment Act (ARRA) - 2009

– The Health Information Technology for

Economic and Clinical Health (HITECH) Act

• $20 billion to aid in the development of a healthcare infrastructure and to promote adoption and use of health information technology, including EHRs

• Requires “meaningful use” of a “certified” EHR

• Provides bonus/incentive payments

L.O 1.6 Nursing Informatics

L.O 1.6 Nursing Informatics

• Florence Nightingale

– Recognized the need for standardization of

nursing language to facilitate communication

and enhance quality care

• Harriet Werley

– first provided nursing input for computer use

in the healthcare arena in the 1950s

• 1970s: Nursing applications for computers began to be developed

L.O 1.6 Nursing Informatics

– Development of personal computers

– Nursing informatics courses

• 1994

– Nursing informatics recognized as nursing specialty

– Scope and standards of nursing informatics practice developed

L.O 1.6 Nursing Informatics

• Nursing informatics

– Supports quality of nursing decisions by

enhancing access to nursing knowledge and

patient information

– Promotes development and use of tools compiled from a variety of sciences

– Assists with managing and communicating

information and knowledge between healthcare

team members

– Promotes access to current evidence-based

nursing practice