A Guide to Electronic Health Records for Nurse Practitioners
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The electronic health record system (EHR) was first developed in the 1960s. Mayo Clinic in Rochester, Minnesota was one of the first major healthcare companies to adopt an EHR. At that time, EHRs were so expensive that they were only used by the government in partnership with healthcare organizations.
Then in the 1970s, the larger hospitals and healthcare systems started utilizing them mainly for scheduling and billing. In the 1980s, EHRs became more affordable and available. However, computers did not gain traction in smaller clinics until they became popular with the general public. By the 1990s, computers were being used mostly for record-keeping purposes in healthcare facilities. EHRs were often seen in academic medical facilities.
Around the same time, the “problem-oriented” patient medical record, even on paper, began to emerge. This is the approach providers use today to document patient visits. Before that, physicians only documented a patient’s diagnosis and the treatment provided. The “problem-oriented” medical record allowed clinicians to collect and store patient medical history data. This became an effective way of communication among all healthcare team members. It also facilitated the coordination of maintenance and preventive care for patients.
Nowadays, most medical systems use EHRs. They are no longer a luxury, but necessary for Health Insurance Portability and Accountability Act (HIPAA) compliance and ideal patient care.
In 2004, President George W. Bush created the Office of the National Coordinator for Health Information Technology. Their goal was to implement EHR within the next 10 years. Today, an EHR is necessary to meet meaningful use requirements. This is a Medicare and Medicaid program that supports the use of an EHR in patient care. To avoid penalties on Medicare and Medicaid reimbursements, authorized providers must follow standards that serve as a roadmap for effectively using an EHR.
What is an EHR?
An EHR is a patient’s comprehensive medical history in a digital format. It securely maintains information across healthcare sectors, such as primary care providers, specialists, and pharmacies. It encompasses patients’ medical history, such as surgical history, social history, and past illnesses. It also displays diagnoses, lab results, radiology images, medications, and immunizations. These are all vital for medical practices in making informed healthcare decisions.
EHRs are interactive systems designed to improve efficiency and accuracy. They offer real-time access to patient data and allows various healthcare providers to collaborate on treatment. EHRs were designed to allow clinicians to share information privately and securely with the patient’s authorization; help prevent medical errors and reduce paperwork; and improve administrative efficiencies and healthcare quality.
EHRs automate and streamline provider workflow. Through these platforms, clinicians can document patient encounters, review lab results, and respond to patient phone messages. They can place orders directly via the EHR, such as lab orders or referrals. Pharmacies may contact providers promptly via the EHR to request medication refills for patients. Specialists send consult notes back to primary care providers via fax, instantly uploaded to patients’ digital charts.
There is an option for NPs and other providers to print patient education material through the EHR. The EHR is linked to evidence-based resources to offer more education to patients. For instance, if a patient is seen for a migraine headache, the nurse or clinician can print out additional material on prevention and treatment of migraine headaches to give to the patient for further reading.
Depending on the practice, patients may have access to a patient portal that allows them partial access to the EHR. There they can find previous lab results, their past medical history, and a vaccine summary. Some practices even allow patients to message nurses or providers via the portal.
Common EHR Systems
There are over 500 vendors of EHR systems these days. The most used EHR examples are:
- NextGen
- Athena
- Epic
- E-clinical Works
- Cerner
- Centricity
- Practice Fusion
- Meditech
- Allscripts
Note that some healthcare facilities create their own internal EHR software, which they tailor to their practices.
Sections of an EHR
The majority of EHRs have the same main sections. However, they can be laid out in various ways. The EHR typically includes:
- Patient contact information and demographics
- Insurance information
- Allergies
- Immunizations
- Family history
- Social history
- Surgical history
- List of medications
- Lab results
- Imaging results
- Referrals
- List of current or previous medical diagnoses
- Health maintenance such as last colonoscopy, mammogram, and pap smear
- Previous medical records
- Hospital records
- Nursing or Physician office visit notes
- Specialist consult notes
- Current and previous orders
- Patient education
- Phone messages
- Growth charts for pediatric patients
Benefits of EHRs
As a result of EHRs, patient medical records are more accessible and safely stored. System administrators can pinpoint users and track their actions when personal healthcare information is entered into an EHR. This secures patient data and protects their privacy in the process. Providers practicing within the same healthcare system can easily see patient medical data within the same EHR.
With EHR use, healthcare practices have less paper waste and increased cost savings. For example, if a patient goes to the emergency room, the provider can see that the patient already had imaging done recently, and there is no reason to repeat a CT scan. This saves the healthcare organization, patient, and health insurance plenty of money. Continuous exchange of health data will reduce the repetitive tasks clinicians often perform.
From a clinician perspective, EHRs improve patient care, increase patient participation, advance care coordination, and improve diagnostics and patient outcomes. Some providers report that EHRs save them time on documentation, giving them more time with their patients. These systems help coordinate clinician workflow management and scheduling. They can also manage order sets, test results, and patient consent.
E-prescribing is a huge benefit, allowing prescribers to order medications quickly and seamlessly. Order sets are when the EHR has an automatic template for frequently used orders for common illnesses. For example, when treating a patient with low back pain, the order set will have “xray” and “ibuprofen 800mg” that the provider can easily click through and order, without having to search each order one by one.
EHRs can automatically share and update patient information within different offices and organizations. There is more efficient storage and retrieval of this information. It is easier to standardize services and patient care. For instance, EHRs can offer clinical reminder alerts when patients are due for health screenings such as mammograms or immunizations.
Moreover, EHRs help reduce medical errors and improve patient safety. With paper records, there may be difficulties in reading penmanship and orders, which can lead to inaccuracies. Digital documentation is easier to read and allows for more accurate billing. EHRs have beneficial functions, such as alerting providers to drug interactions when prescribing new medications that can prevent harm. It can also alert prescribers to a patient’s medication allergies, thus preventing medical errors.
Summary: The Usefulness of Modern EHRs in Nursing Practice
EHRs have become an indispensable tool in today’s healthcare practice. The benefit of an EHR is not only in the data it contains but how it is shared. Health information has become instantly available to authorized clinicians across health organizations, allowing them to coordinate care efficiently. EHRs present critical data that focuses on the total health of the patient. Patients often have access to this information, allowing them to be more informed about their care.
Sophia Khawly, MSN
WriterSophia Khawly is a traveling nurse practitioner from Miami, Florida. She has been a nurse for 14 years and has worked in nine different states. She likes to travel in her spare time and has visited over 40 countries.
Being a traveling nurse practitioner allows her to combine her love of learning, travel, and serving others. Learn more about Sophia at www.travelingNP.com.