Electronic Health Record Systems

Last Updated on 03/23/2023 by Sophia

(a) the topic title; Effects of Electronic Health Record Systems to Patient Safety and Quality
(b) an outline that begins with an introduction, background or overview;
(c) significance or purpose of the paper;
(d) major and sub-headings to organize the development of the topic;
(e) a section on how technology or concept in NI factor into your topic;
(f) your role as a nurse practitioner
(g) descriptors (or thesis) for each heading and sub-heading, with appropriately written in-text
citations that include page numbers, and;
(h) an annotated bibliography (reference listing following correct APA style) of 5 relevant scholarly
articles written in a synthesized format. Articles must be current, from peer-reviewed journals, and
published within the last five (5) years. Submit this as one file via Moodle. This is a graded exercise and
the professor will critique and offer suggestions to improve your work, if necessary.

Make certain to utilize an outline for your paper that includes: (1) significance of the paper, (2) major
headings, and (3) sub-headings, as appropriate. Utilize the APA form. The paper should be 6 pages in
length that do not include the title page, abstract, references, and appendices

 

Answer

Introduction
An Electronic Health Record refers to a modern version of keeping a record of a patient's
medical history electronically. It includes record keeping of clinical data relevant to each patient,
such as medications, vital signs, laboratory results, and patient's medical history (Centers for
Medicare & Medicaid Services, 2017). The Electronic Health Record System is, therefore, a
system in which health-related information is stored electronically for the safety of clinical data
and easy access to provide patients with the best care. The system allows authorized staff within
a healthcare organization to create, gather, and manage electronic records (Guise et al., 2020).
Through these systems, the quality of patient care and patient safety is improved. Such an
approach, therefore, plays a vital role in modern healthcare. This paper aims to analyze the
Electronic Health Record (EHR) system's effects on patient safety and quality.
Positive Effects of Electronic Health Record Systems to Patient Safety and Quality
First and foremost, the advanced methods of recording health-related information
compared to traditional meals of keeping hardcopy records allow physicians to easily access
patient information, such as diagnoses, allergies, lab results, and medications (Guise et al., 2020).
According to Wang & Wright (2020), many health institutions recorded complaints from their
clinical staff concerning the burden of data entry of health-related information. Such pressing
issues in health care systems resulted in increased burnouts and lower job satisfaction among the
clinical team. Physicians observed a decreased face-to-face time with the patients, and as a
result, the quality of care given to patients was poor. Most patients' medical history also was
scattered because of the numerous clinical notes stored for references. However, with the
introduction of electronic means of maintaining health records, the quality of care service and

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safety recorded a significant improvement (Wang & Wright, 2020). Clinicians can easily access
each patient's health-related information, thus improving the quality of care.
Electronic Health Record Systems allow easy access to new and past test results among
providers in various health care institutions. Again, the system proves to be beneficial to
healthcare providers by improving how they access patients' test results irrespective of how they
obtained the results. The ease of access to new and past test results by providers is due to the
improved documentation of data brought about by the system (Tubaishat, 2019). The enhanced
accessibility of patient test results leads to improved quality of care given to patients.
In the case of computerized provider order entry in clinical work, EHRs have eased the
process of entering and sending treatment instructions. Such instructions include radiology
orders, laboratory results, and medication (Guise et al., 2020). As compared to conveying health-
related information through paper or telephone, medical staff can produce standardized and
complete orders through the use of computerized provider order entry. The automated provider
entry reduces errors and improves patient safety. Submitting health records through electronic
means enhances efficiency by allowing hospitals to save on time and give better services.
Computerized systems provide secure communications among providers and patients.
Sensitive information between patients and care providers becomes protected through the use of
EHRs. A patient can communicate with their health providers from the comfort of their home
concerning any health-related issue that needs are urgent such as questions asked in the case of a
developing condition. Patients can also discuss the progress concerning their health, and at the
same time, the provider can monitor the patient's progress. The communication carried out
electronically is considered secure compared to information transcribed on hard copies easily lost

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or stolen. At the same time, patients can access disease management tools as well as health
information resources.
Moreover, health providers can easily schedule appointments with their patients
electronically. The system allows them to organize consultations with their patients, which saves
on time electronically. Patients can order tests through electronic means and receive their test
results without necessarily going to the hospital. The data obtained is stored in an electronic
manner, which increases patient information safety in the healthcare organization database.
Accessing patients' medical history by the caregivers becomes an easy task that allows them to
assess each patient's needs.
Adverse Effects of Electronic Health Record Systems to Patient Safety and Quality
Healthcare providers using EHR may suffer from poor navigation. While using the
system, poor navigation results from physicians not taking part in appropriate training on how to
go about it. In such a case, the hospital's quality of care reduces because the person handling a
patient may fail to enter data as required. As a result of inappropriate records of data, then the
patient's safety is at risk as cases such as wrong medical prescription may arise. Attempts to sign
the treatment plans for patients may also fail due to healthcare providers' failure to use the
Electronic Health Record System properly. Despite having taken part in training, some clinicians
may have difficulty procedural knowledge (Blijleven et al., 2017). In such a case, the health
official must ask for assistance to review their draft order before administering any form of
treatment to improve patient safety.
Another challenge associated with EHRs is difficulty in finding the right information in
the system. Data options that exist in the system may not be the desired results required by
physicians, such as the type of medication they intend to administer to their patients. According

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to Blijleven et al. (2017), EHRs also make it challenging to enter symptoms into a patient's
problem list and alter a patient's current regimen. Blijleven et al. (2017) give an example of a
physician who wanted to administer a 3.75mg tablet, but the system made it difficult because it
only recorded 2.5mg. The researchers concluded that the system could not predict certain
medication types needed to break down into half. According to the hospital policy, the drug
ordering functionality of EHR is programmed to list medicines according to its pharmacy
inventory.
EHRs restricts the presentation of data because it does not support all clinical work.
Clinical data presentation may be in the form of graphs or charts. There are various types of data
that clinicians cannot present without the aid of charts and graphs. In such a case, EHRs restrict
how health-providers present data in hospitals, for example, showing a patient's blood test results
over a specific period. Such a situation may require the clinician to present results in the desired
form, for instance, on a piece of paper, which reduces the quality of data.
Disrupted workflows due to the sequence of work practices is another effect of Electronic
Health Record Systems. In most healthcare institutions, numerous tasks are performed
simultaneously due to the frequent flow of patients daily. Task interference hinders the quality of
data recorded. According to Blijleven et al. (2017), HER users might find themselves writing
down a patient's data on paper to transfer the data to the computer but ends up missing to enter
the data in the correct fields. Some physicians will argue that it is due to their profession's nature,
whereby they find it difficult to simultaneously examine patients while entering data on the
computer screen (Blijleven et al., 2017). The result is reduced quality of the care given to
patients.

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Impacts of Technology on Patient Safety
Improved patient safety is a result of technological advancements, especially in the
healthcare industry. Some of the technological advances in healthcare organizations include
Remote patient monitoring, Electronic incident reporting, Patient electronic portals, and
Automated medical dispensary technology. According to Alotaibi & Federico (2017), health
information technology plays a vital role in reducing medical errors, and improving compliance
to practice guidelines, improving patient safety. However, they believe that some technologies
are insignificant in enhancing patient safety and therefore recommend that healthcare
organizations select the most appropriate type of technology to invest in adopting. Electronic
Health Record Systems relate to modern technologies that are highly used in healthcare
organizations to improve patient safety. Furthermore, the system's use proves to have many
positive impacts on patient safety and quality as compared to the adverse effects. With the
technological advancements, the chances of medical errors become minimal, and also the quality
of care given to patients improved.
Role as A Nurse Practitioner
As a nurse practitioner, my role would be to ensure that I use the Electronic Health
Record Systems as per the requirements effectively. For instance, in areas where I feel I may fail
to understand some features in the system, I would request further training. The next step would
be to ensure that I record the correct data when transferring the information to the computer. If
possible, I would seek a second reading on my noted draft from another nurse practitioner before
recording the data electronically. The possibility of medical errors would be reduced, thus
promoting patient safety and quality.

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In addition, I would note down the issues or challenges that I might be facing while using
the system, such as system failure for necessary enhancements to ensure smooth access to the
data in the system. Another issue that might occur due to the system is the failure to present data
in formats such as graphs and charts. In such a case, I will ensure to look for the best alternatives
to ensure that I deliver data in the desired format that is efficient. To meet the desired objective
of improved medical care, I would also ensure that my patients are well equipped with the
technology to communicate effectively with them concerning their test results and follow up on
the health records and progress.
Electronic Health Record Systems proves to be an improvement in healthcare
organizations. The modern technology of creating, recording, and electronically storing medical
information ensures positive healthcare results compared to producing negative results. The
quality of care given to patients has significantly improved with a minimal reduced number of
cases such as medical errors. Patients are now able to do consultations electronically and book
appointments with their doctors with much ease. They are also able to get their test results faster
in a more convenient manner. The Electronic Health Record Systems has created a platform for
storing vast amounts of data that can easily be accessed at any time regardless of whether the
data is new or from records. However, the system has demonstrated negative results, but with the
correct advancements, they can be addressed and improve patient care and safety quality.

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References

Alotaibi, Y., K., & Federico, F. (2017). The impact of health information technology on patient
safety. Saudi medical journal, 38(12), 1173.
Blijleven, V., Koelemeijer, K., Wetzels, M., & Jaspers, M. (2017). Workarounds emerging from
electronic health record system usage: Consequences for patient safety, the effectiveness
of care, and care efficiency. JMIR human factors, 4(4), e27.
Centers for Medicare & Medicaid Services (CMS), HHS. (, 2017). Medicare Program; Hospital
Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term
Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018
Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid
Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals,
Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian
Health Service and Tribal Facilities and Organizations; Costs …. Federal
register, 82(155), 37990.
Guise, J. M., Reid, E., Fiordalisi, C. V., Borsky, A., & Chang, S. (2020). AHRQ Series on
Improving Translation of Evidence: Progress and Promise in Supporting Learning Health
Systems. Joint Commission Journal on Quality and Patient Safety, 46(1), 51-52.
Tubaishat, A. (2019). The effect of electronic health records on patient safety: a qualitative
exploratory study. Informatics for Health and Social Care, 44(1), 79-91.
Wang, E. C. H., & Wright, A. (2020). Characterizing outpatient problem list completeness and
duplications in the electronic health record. Journal of the American Medical Informatics
Association, 27(8), 1190-1197.