How Electronic Medical Records Can Improve Patient Safety
By Sarah Stasik, Contributor
Love 'em or hate 'em, electronic medical records are around for the long haul. And while they certainly add computing time to nursing shifts, they can also make charting easier and help improve overall patient safety. Check out some ways EMRs contribute to increases in patient safety below.
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EMRs Help Reduce Medication Errors
Stan Loskutov of Medical Billing Group says that EMRs make it "easier for medical staff to be more organized with patient medical data," which leads to a variety of benefits.
At the most basic level, an EMR removes a previously common problem for healthcare teams: illegible handwriting. Loskutov notes that a properly used EMR leads to patient treatment becoming "more reliable by eliminating clinical errors due to unreadable handwriting."
Clearer records lead to less guessing between healthcare providers and shifts. For example, a nurse on the night shift no longer needs to wonder if the medication ordered earlier in the day was for three times daily and whether a dose was already given. In a properly maintained EMR, that information is available with a quick glance.
Electronic Medical Records Can Improve Diagnostics
It's not just that notes become easier to read, reducing risks of basic errors. Electronic medical records also gather much of the information vital to clinical decision-making in a single location, increasing the chance that the right diagnosis will be arrived at earlier. In fact, in a national survey regarding electronic health records, 75 percent of doctors said the technology allowed them to provide better patient care.
EMRs Reduce Adverse Events in General
Medication errors and missed diagnoses are just two of the potentially adverse events that can happen to a patient in a medical facility. Examples of other types of adverse events can include miscommunication between staff, late treatment, patient falls or infection.
But EMRs don't discriminate when it comes to reducing such activity —according to a study funded by the Agency for Healthcare Research and Quality, EMR use reduced adverse events for pneumonia, surgery and cardiovascular patients by 17 to 30 percent in hospitals. For example, if a nurse on one shift notes that a patient is at risk for falls and records that in the medical record, the EMR will notify all other nurses to take appropriate safety precautions.
Proper Use of an EMR Leads to Better Integrated Care
"EHRs . . . improve care coordination," says Shereese Maynard, a health IT strategist. This can be important for clinicians treating chronic or complex cases, because they may be working as part of an overall health team.
For example, nurses working with a cancer patient may need to coordinate care across specialties including oncology, radiology and surgery. Electronic medical records reduce the time spent on paperwork and phone calls and make the entire medical record immediately available to all applicable providers.
The result of EMRs is often greater efficiencies, a better concentration on the patient and high-level teamwork that leads to solutions that might otherwise not have been arrived at —or that nurses and other staff might have arrived at too late for a positive outcome.
HIPAA-Compliant Electronic Medical Records Protect Patient Privacy
Loskutov says the protection of patient information provides some safety benefits. At the very least, knowing their extremely personal information is safe with a HIPAA-compliant EMR can reduce some stress for a patient. And when records are secure, there's less of a chance of cross-documentation (one patient's information being recorded to another patient's record).
Plus, the medical record is always available when it's in electronic format —EMRs are usually backed up on redundant servers, so they can't be accidentally damaged by a coffee spill or inadvertently tossed in the shredder. If the medical record isn't available, clinicians can't make safe and appropriate patient care decisions based on it.
Loskutov says an electronic medical record is much more secure than old-fashioned paper charts, which he says "can be misplaced, stolen or destroyed."
Increased Rate of Patient Compliance with At-Home Care
Electronic medical records can also lead to improved compliance with follow-up and home care. First, EMRs are simply better at providing the type of written instructions that help patients stay on task with follow-up at home. Nurses don't have to customize forms or type out lengthy instructions; good EMRs allow nurses to complete a quick checklist to create discharge paperwork that includes comprehensive information for patients.
In some cases, EMRs include patient portal options, letting patients view records online or communicate with providers via the system. While these systems do have drawbacks and implementation challenges,a study published by the Journal of the American Association of Nurse Practitioners noted a patient preference for EMRs over paper records. That preference can lead to increased adherence and communication on the part of the patient, which can increase positive outcomes.
Nurses should note that electronic medical records aren't a magic wand that solves long-term healthcare challenges, including communication and resource issues. But they are a tool that can be used to help reduce the sting of these challenges, all while increasing the quality of patient care and improving patient safety.
As an RN, you'll likely be tasked with learning how to operate within EMR systems in any role you take on. Make sure you know how to leverage this tool and avoid common electronic medical records mistakes to keep your patients, yourself and your career as safe as possible.