Electronic health record and electronic patient record

This article considers the government plans for the development of electronic health and patient records as set out in the NHS Plan and the progress and problems which have been encountered in their realization.     

Assessing organizational readiness for electronic health record adoption in long-term care facilities

Methods to support long-term care (LTC) providers to successfully implement electronic health records (EHR) are vital as they move to leverage the potential for improvements in quality, efficiency, and effectiveness through EHRs. This article reports the development of a readiness assessment tool to allow LTC facilities to measure their capacity for successful EHR implementation. The LTC Readiness Assessment Tool for EHR Implementation was developed through a literature review and qualitative study to establish content validity, followed by the current study to assess the tool's internal reliability. The tool was mailed to administrators or directors of nursing at 600 LTC facilities in Texas with instructions for survey completion. Ninety-three surveys were returned. Item means ranged from 2.72 to 5.07 on a 7-point scale (1 = strongly disagree to 7 = strongly agree), with the category of state regulatory support receiving the lowest mean and physical plant requirements receiving the highest. Internal reliability was supported with a Cronbach's alpha coefficient of 0.95.     

SNOMED CT: electronic health record enhances anesthesia patient safety

This article discusses the importance of electronic health records (EHRs) in anesthesiology, emphasizing the critical role of standardized clinical terminology in the EHR's structure. SNOMED Clinical Terms (SNOMED CT), developed by SNOMED International, a division of the College of American Pathologists, in collaboration with the United Kingdom's National Health Service, offers a controlled healthcare terminology with comprehensive coverage of diseases, clinical findings, etiologies, therapies, procedures, and outcomes. Recommended as the core general terminology for electronic patient medical record information in the United States, it offers flexibility in expressing clinical concepts, enabling clinicians to say things in multiple ways and still be understood. SNOMED CT's comprehensive, scientifically validated clinical terminology enables a consistent way of capturing, sharing, and aggregating health data across specialties and sites of care. Its benefits range from facilitating system interoperability to allowing greater shared access to patient health information where and when it is needed. The article concludes by informing readers of access to English and Spanish language editions of SNOMED CT's core content, which recently was licensed through the National Library of Medicine, a part of the National Institutes of Health within Department of Health and Human Services.     

The electronic medical record, safety, and critical care

The goal of this article is to introduce the elements of the Electronic Medical Record as they pertain to critical care medicine including order communications and decision support.     

The role of theory in improving patient safety and quality health care

By examining selected research that investigates the relationship between nurse staffing and adverse events, we demonstrate the problems that result from the absence of a strong theory to guide this research. There is considerable work to be done in explicating the theory underlying empirical studies of the relationship between nurse staffing and outcomes. Key constructs must be placed within a theoretical context, proposed causal mechanisms underlying the empirical or hypothesized relationships must be identified, and critical mediating and moderating variables must be recognized.     

Improved quality and comprehensiveness in nursing documentation of pressure ulcers after implementing an electronic health record in hospital care

Aims. One aim was to compare the quality and comprehensiveness in nursing documentation of pressure ulcers before and after implementation of an electronic health record in a hospital setting. Another aim was to investigate the use of preformulated templates for pressure ulcer recording in the electronic health record. Background. With the possibilities of the electronic health record to provide information and give accurate and reliable feedback to the healthcare organisation, it is of high priority to develop standardised documentation practices for various areas of care (e.g. such as pressure ulcer care). Design. A cross‐sectional retrospective review of health records. Methods. Three departments in a Swedish university hospital participated. In 2002, there were 413 patients, including 59 paper‐based records identified with notes on pressure ulcers and in 2006, 343 patients, including 71 electronic health records with pressure ulcer recording. Recorded data on pressure ulcers were retrospectively reviewed. Results. Significantly more patient records showed notes of pressure ulcer grade (p < 0·001), size (p = 0·004), risk assessment (p = 0·002), nursing history (p = 0·040), nursing diagnoses (p < 0·001), nursing goals (p < 0·001) and nursing outcomes (p = 0·016) in 2006 than in 2002. One third of the recordings used preformulated templates. Conclusions. Although there were significant improvements in pressure ulcer recording after the change to the electronic health record, several deficiencies remained. Due to the short time of our follow‐up after implementation of the electronic health record, we suspect that the quality of recording will improve when nurses become more familiar with the new system. Relevance to clinical practice. Education related to the use of the electronic health record and evidence‐based pressure ulcer prevention should be provided to the nurses. To facilitate documentation, the templates need to be refined to be more user‐friendly.     

The effect of lifestyle interventions on quality of life and patient satisfaction with health and health care

Improvements in quality of life (QOL) and high levels of patient satisfaction are associated with cardiovascular risk reduction (CRR) programs. Understanding the influences that lifestyle change and medical management have on individuals, their families, and their environment can help target successful interventions that benefit both QOL and patient satisfaction. It is well known that multiple aspects of one's QOL can be affected by the development of coronary artery disease. Development of depressive symptoms and anxiety, along with declines in functional capacity and family and social functioning, has been reported. QOL is a dynamic continuum, relating to many aspects of one's life. Social relationships, financial situations, work-related issues, physical limitations, and intellectual challenges all play a role in determining QOL and satisfaction within the health care setting. Self-perception of how these factors negatively or positively influence one's QOL also exerts a strong influence. This article will review the influence of primary and secondary prevention programs on QOL and patient satisfaction.     

Information systems and the electronic health record in primary health care

The implementation of information systems into primary health care opened the possibilities of providing integrated and co-ordinated health care, improved in quality and focused on the healthcare user. The healthcare system, researchers, physicians, and patients have recognised the benefits offered by informatics, but also raised questions that have yet to be answered.     

Improving drug abuse treatment delivery through adoption of harmonized electronic health record systems

A great divide currently exists between mainstream health care and specialty substance use disorders (SUD) treatment, concerning the coordination of care and sharing of medical information. Improving the coordination of SUD treatment with other disciplines of medicine will benefit SUD patients. The development and use of harmonized electronic health record systems (EHR) containing standardized person-level information will enable improved coordination of healthcare services. We attempt here to illuminate the urgent public health need to develop and implement at the national level harmonized EHR including data fields containing standardized vocabulary/terminologies relevant to SUD treatment. The many advantages and barriers to harmonized EHR implementation in SUD treatment service groups, and pathways to their successful implementation, are also discussed. As the US Federal Government incentivizes Medicare and Medicaid Service providers nationwide for "meaningful use" of health information technology (HIT) systems, relevant stakeholders may face relatively large and time-consuming processes to conform their local practices to meet the federal government's "meaningful use" criteria unless they proactively implement data standards and elements consistent with those criteria. Incorporating consensus-based common data elements and standards relevant to SUD screening, diagnosis, and treatment into the federal government's "meaningful use" criteria is an essential first step to develop necessary infrastructure for effective coordination of HIT systems among SUD treatment and other healthcare service providers to promote collaborative-care implementation of cost-effective, evidence-based treatments and to support program evaluations.     

Development of an electronic emergency medical services patient care record

Objective. The need for valid and reliable emergency medical services (EMS) data has long been recognized. EMS data are useful for monitoring resources and operations, documenting patient care and outcome, and evaluating injury prevention strategies. The goal of this project was to develop a computerized data set with the capability to generate a patient care record (PCR) to overcome some of the current EMS data limitations. Methods. The authors discuss developing an electronic PCR and analysis data set containing 233 variables. Data are collected for the following: incident, response, scene, patient, history, primary survey (including vital signs), physical examination, physiologic scores, diagnostics, plan (medications and procedures), assessment, and reevaluation. Software on a portable computer installed in an EMS response unit utilizes a graphical user interface for data collection by prehospital emergency care providers. A data set stores codes corresponding to user's selections. This data set supports data storage and analysis. The electronic PCR and data set can be useful to EMS agencies for collecting, storing, reporting, and analyzing information. Results. Variables are categorized into 12 main categories to categorize the variables and to drive data collection. The system provides the user with the ability to print out a record (using a portable printer installed in an ambulance) and analyze data stored in the data set. Conclusions. This computerized approach overcomes many limitations inherent with using paper-based systems for research. Linked with emergency department, hospital discharge, and mortality data, EMS data can be used in systems analyses related to patient outcome.