Tasked with doing the majority of patient charting, the responsibility of maintaining health records most often falls with nurses. By now, most hospitals have moved to electronic health records (EHR). First off, let's clarify the difference between electronic medical records (EMR) and EHR.
Some people use the terms interchangeably, but the Office of the National Coordinator for Health Information Technology (ONC), part of the U.S. Department of Health and Human Services, uses EHR almost exclusively. As they explain, the term EMR came along first because the medical records were used by clinicians mostly for diagnosis and treatment. EMRs are a digital version of the paper charts. An EMR contains the medical and treatment history of a patient in one setting. But the information in an EMR doesn’t travel easily out of the facility. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team.
EHRs go a lot further than EMRs. EHRs focus on the total health of the patient—going beyond standard clinical data and inclusive of a broader view of a patient’s care. They are built to share information with other healthcare providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The information is designed to move with the patient to the specialist, the hospital, the nursing home, the next state, or even across the country.
Do the benefits of new EHR systems outweigh any user frustrations? A recent report in Modern Medicine claims that nurses are growing increasingly dissatisfied with their facility's electronic health record systems. But it's not the software itself that's frustrating. It's the lack of communication between staff and administrators. In the survey, 98% of nurses said administrators have never sought nursing opinions on the functionality of their EHR systems.
Nurses claimed that EHR systems are often selected based on price rather than performance and usability. Another complaint from the nurses polled was IT department incompetence and slow response to system problems.
As a nurse and frontline user of this technology, if given the chance to test software systems and provide feedback, what qualities are you looking for in an EHR system?