Inpatient Electronic Health Records Clinical System

Clinical systems play a vital role in strengthening healthcare delivery throughout the world. All healthcare organizations and professionals must try and adopt the various clinical systems in their organizations. The development of clinical systems and other information technologies in healthcare are related to improved patient outcomes and efficiencies.

They are crucial to delivering patient-centered and evidence-based care, decreasing medical errors, boosting the quality of care, increasing legibility, and reducing healthcare costs (Islam et al., 2018). In-patient electronic health records are a clinical system known to enhance access to healthcare and improve patient outcomes.

The electronic health record is used in hospitals to store and retrieve various patient information so that healthcare practitioners can use it in patient care. This paper seeks to elaborate on how electronic health records have improved outcomes and efficiencies in healthcare by critiquing various research articles.

Hazazi, A., & Wilson, A. (2021). Leveraging electronic health records to improve management of non-communicable diseases at primary healthcare centers in Saudi Arabia: a qualitative study. BMC Family Practice, 22(1). https://doi.org/10.1186/s12875-021-01456-2

The study’s main aim was to examine the physician’s perspective on the contribution of the electronic health records systems in managing chronic diseases in primary healthcare centers. The study design used was qualitative, mainly involving semi-structured interviews among physicians who work in the primary healthcare centers with experience of at least one year. Convenience and purposive sampling were applied when the participants were selected. The sample obtained was 22 physicians who work in chronic diseases clinics.

The physicians reported that the application of the health information systems in their clinics has positively influenced patients with chronic diseases. It has resulted in more efficient patient care because the patient’s records and results are always available in the systems. The presence of the patient information allows the physicians to come up with diagnoses, treatments, and follow up effectively and, therefore, improve patient outcomes.

They also reported that EHR enhances accurate patient documentation, which is very rare in handwritten documentation. It also enhances early screening of non-communicable chronic diseases and, therefore, early detection and treatment of comorbidities. Through electronic health records, physicians can easily manage patients by prescribing medications and facilitating referrals.

The research shows that using EHR in primary healthcare centers is associated with various positive benefits. It is vital to allow patients with non-communicable chronic diseases to access the EHR systems to manage chronic diseases. Electronic health records are a clinical system that has greatly supported positive patient outcomes and effectiveness among patients with chronic illnesses. Linking the HER to other government and private facilities can enhance communication and patient care integration, leading to improved patient outcomes.

Selvaraj, S., Fonarow, G. C., Sheng, S., Matsouaka, R. A., DeVore, A. D., Heidenreich, P. A., Hernandez, A. F., Yancy, C. W., & Bhatt, D. L. (2018). Association of Electronic Health Record Use With Quality of Care and Outcomes in Heart Failure: An Analysis of Get With The Guidelines—Heart Failure. Journal of the American Heart Association, 7(7). https://doi.org/10.1161/jaha.117.008158

The article mainly focused on how the use of electronic health records is associated with quality care and outcomes among patients with heart failure. There has been an increase in the adoption of electronic health records worldwide. However, no studies have been conducted to assess whether it improves outcomes among patients with heart failure.

The sample was obtained from patients admitted in 2008 in Get With The guidelines -HF registry. The researchers obtained detailed patient information and also the various hospital-level characteristics. A longitudinal study design was used during the research. The statistical analysis mainly involved a cross-sectional and survival analysis.

Selvaraj et al. (2018) explain that through electronic health records, there can be improved care coordination, resulting in improved efficiency. The findings in the study indicated that the application of electronic records among patients with heart failure is not associated with improved quality of care based on the in-patient outcomes, predefined metrics, and other post-discharge events.

Electronic health records can have unintended adverse effects like; medication errors, increased mortality, and provider dissatisfaction. Although some of the findings indicated that electronic health records could be associated with less frequent length of stay and higher rates of discharge, it is also associated with a poor achievement rate of some measures such as smoking cessation counseling.

According to the article, using electronic health records alone among heart failure patients may not help improve patient outcomes and efficiency. It is therefore vital to set in place other interventions in addition to EHR to help improve the quality of care among those patients. It is essential to ensure increased optimization of EHR in this era because of the increased adoption of technology because there are many theoretical benefits related to its use.

Upadhyay, S., & Hu, H. (2022). A Qualitative Analysis of the Impact of Electronic Health Records (EHR) on Healthcare Quality and Safety: Clinicians’ Lived Experiences. Health Services Insights, 15, 117863292110707. https://doi.org/10.1177/11786329211070722

The study aimed to find out clinicians’ experiences in assessing the contributions of EHR in enhancing safety and improving the quality of care in healthcare. The study design used was qualitative. Semi-structured interviews were used among various healthcare practitioners in California and Nevada in the U.S.

There were 20 participants in the study, and they included individuals from different organizations, including; medical clinics, small hospitals, trauma hospitals, hoke health centers, and academic medical centers with different job roles including; nurse practitioners, physicians, patient safety officers, hospitalists and nurses.

The findings indicated that EHR makes communication between patients and clinicians more efficient. The clinician can be able to access past patient procedures and other histories. Through clear communication, electronic health records enhance clear understanding among the nurses, physicians, and therapists, and therefore informed decisions can be made, resulting in improved patient care outcomes. Electronic health records are a critical factor in improving the quality of care.

EHR has enabled the nurses to mitigate the risk of medical errors because they can clarify the interactions or side effects of medications before administering them. Patient safety can be enhanced because electronic health record provides notifications, reminders, and alerts. The results also indicated that EHR enables the healthcare providers always to set informed decisions that can play a role in improving patient outcomes.

Evidently, electronic health records help clinicians make informed decisions, reduce medical errors, and enhance safety, which is essential in improving patient outcomes and effectiveness of care. Electronic health records contain all the patient information. They can be easily accessed by the various healthcare practitioners working together as a team, such as nurses, and physicians’ therapists, among others, in providing patient care.

EHR enhances accurate documentation of data which is related to effective patient safety. From the research, it is vital to train various healthcare practitioners on using electronic health records in case of any change or advancement because it greatly affects the quality of care.

Uslu, A., & Stausberg, J. (2021). Value of the Electronic Medical Record for Hospital Care: Update From the Literature. Journal of Medical Internet Research, 23(12), e26323. https://doi.org/10.2196/26323

The research aims to summarize the value of electronic medical records. The method adopted from this research was from various literature reviews, and it involved a literature search of Edline; the keyword used was “Medical Record, system, Computerized .”The evaluation of data sources mainly involved a qualitative assessment of the medical records of publications, description of sources of data, and scoring of quality of studies. There were 1345 literature references to be reviewed by the authors, and in the end, they chose 23 studies that were relevant for the research. A semiquantitative study evaluation was applied in the research.

All the 23 articles demonstrated a positive effect of electronic health records on the quality of care provided in all the healthcare organizations. 9 out of 16 of the secondary sources demonstrated decreased costs. At the same time, 14 of 18 studies indicated an increase in the quality of care. The EHR has greatly helped in reducing time for documentation and reducing various medication errors.

The decrease in medication errors is related to improved patient safety and, therefore, better health outcomes. There was no relationship found between mortality and the use of electronic health records. The introduction of electronic medical records is related to the various technological processes, and its introduction has resulted in many clinical benefits.

This article shows that the application of electronic medical records in-hospital care is related to reduced medical errors and improved quality of care. Therefore, EHR can facilitate safe continuity of care and improve patient outcomes and efficiency. From the various articles assessed, since the adoption of EHR, the various processes in healthcare have been made easy and faster.

Conclusion

To sum up, clinical systems are essential in the healthcare setting. Electronic health records is one of the clinical system known to improve patient outcomes and enhance effectiveness and efficiency in the healthcare setting. All four pieces of research indicated the various ways the electronic health record reduces medication errors, enhances coordinated care among the care practitioners, and enhances accurate documentation, resulting in improved patient outcomes.

The efficiency is evident in electronic health records because of the teamwork and collaboration among the care practitioners, including the nurses, physicians, therapists, and lab technicians. The studies have also elaborated on how the EHR reduces healthcare costs and saves time used to deliver healthcare. The use of electronic healthcare records among in-patients is therefore essential, and the healthcare facilities should try to adopt it and make improvements for it to function effectively.

References

Islam, M., Poly, T. N., & Li, Y.-C. J. (2018). Recent Advancement of Clinical Information Systems: Opportunities and Challenges. Yearbook of Medical Informatics, 27(1), 83–90. https://doi.org/10.1055/s-0038-1667075

Inpatient Electronic Health Records Clinical System Instructions

To Prepare:

Reflect on the impact of clinical systems on outcomes and efficiencies within the context of nursing practice and healthcare delivery.
Conduct a search for recent (within the last 5 years) research focused on the application of clinical systems. The research should provide evidence to support the use of one type of clinical system to improve outcomes and/or efficiencies, such as “the use of personal health records or portals to support patients newly diagnosed with diabetes.”
Identify and select 4 peer-reviewed research articles from your research.
For information about annotated bibliographies, visit https://academicguides.waldenu.edu/writingcenter/assignments/annotatedbibliographiesLinks to an external site.

The Assignment: (4-5 pages NOT including the title and reference page)

In a 4- to 5-page paper, synthesize the peer-reviewed research you reviewed. Format your Assignment as an Annotated Bibliography. Be sure to address the following:

Identify the 4 peer-reviewed research articles you reviewed, citing each in APA format.
Include an introduction explaining the purpose of the paper.
Summarize each study, explaining the improvement to outcomes, efficiencies, and lessons learned from the application of the clinical system each peer-reviewed article described. Be specific and provide examples.
In your conclusion, synthesize the findings from the 4 peer-reviewed research articles.
Use APA format and include a title page.
Provide a reference page.