Health care, according to the Canada Health Infoway and Health Council of Canada (2006), is the most information intensive industry of the world. For every day, massive volume of data that can improve clinical practice and outcomes, guide planning and resource allocation, and enhance accountability are produced. With these, the health care has embraced the information technology revolution. One of this is the adoption of electronic health records.
Electronic health record (HER) has been viewed by policy makers and clinicians as a tool towards better quality in health care and revitalization of clinical practice (Corrigan, Greiner, & Erickson, 2002). In effect, the New South Wales Ministerial Advisory Committee on Privacy and Health Information (NSW-MACPHI) (2000) witnesses to a trend towards the widespread adoption and use of this information technology. But as in any other technology, EHR, too, promises transformation in the practice of clinical professionals. Among these health care providers affected by changes are the traditionally paper-record-user nurses.
With this consideration, this paper probes on the effects of EHR to nursing practice weighing both the benefits and risks and looking at its transformational outcomes to the practice and strategies geared toward those process changes. What is EHR? The Health Information Management Systems Society as cited by the National Institutes of Health – National Center for Research Resources (NIH-NCRR) (2006) defines EHR as: “… a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.
Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface—including evidence-based decision support, quality management and outcomes reporting. ” (p. 1)
In short, EHR is the replacement of the paper record and includes the original contents of patient charts that is encoded, generated, and stored electronically. Plus, additional functionality can be seen in EHR’s as they also provide interactive alerts to clinicians, interactive flow sheets, and tailored order sets (NIH-NCRR, 2006). Thus, EHR has gained favor with the Institute of Medicine (IOM) with IOM including “Utilization of Informatics” in its five core competencies as these information technology tools can be used to communicate data, manage knowledge, mitigate error and support decision-making (Peterson, 2003).