electronic medical record

The incredible electronic medical record, friend or foe to the registered nurse?

Since the rise of computerized physician order entry, meaningful use requirements and regulations, electronic medication administration records, the EMR has become a new necessity of the hospital. 

The American Reinvestment and Recovery Act (ARRA) was formed in 2009 in an attempt to improve the infrastructure of the healthcare system, thru technological advancements and the use of the electronic medical record. The goals of this initiative are designed around patient safety, improved care cordination, patient and family engagement, while providing security and privacy (CDC Meaningful Use) 

I would like to examine the EMR from the Registered Nurses perspective!

When the EMR Works:

The nurse logs into the EMR and pulls up all the data they need to care for the patients they are assigned. The medication lists, histories, medical notes, and everything needed to care for the patient. You scan the medication, ensuring the right patient, right drug, right time, right dose, and right route are provided. Vital signs are entered showing the patient is stable or interventions are in place to make them stable. Plans of care discuss ways of improving the person's overall health or situation. In a nut shell when the EMR works it can work well and certainly carry out the goals it was intended for.

When the EMR doesn't work!

Unfortunately we know technology is only great when it works. The nurse logs in, however their password has expired. A call to the help desk warrants an additional 20 minutes of the nurse's time before care reaches the patient. Once logged in the nurse logs in and begins researching the patient's. 

Later on in the day the server has issues, thus connectivity goes down and the nurse loses the electronic medical record. Paper copies of the medication record are sent to the unit and the nurse must remember to use all the old ways of doing things. Scanning a pill will not verify if it is correct!

Lately, in the news we have all seen how secure our EMR can be. With adware and spyware and whatever the latest threat may be, our EMR is under attack from people who want money! Patient's records are at risk for exposure, sale, and personal identity theft. 

An initiative designed to keep medical information safe now threatens to shut down hospitals for large sums of money. This would be impossible for hackers to do if all this data remained in paper charts in medical records rooms. Although, us older nurses  remember those charts. Wow were they thick! I recall charting red ink at night, green for evening, and black for day shift!

Read this 10 Things You Hate About Your EMR Article!

EMR Benefits to the Nurse

  1. Eligibility of orders - You can actually read them!
  2. Improved Accuracy 
  3. Quick access to information
  4. Communications about prior and current admissions

What will the next 10 years bring?

Technology has advanced in just a matter of a decade. What will the next decade bring? I always felt  a system that could hear the nurse talk to the patient and to the providers and figure out just where to document it so it made sense, thus allowing the nurse to just take care of patients would be the best. Of course if I could figure that out then I would be sipping cocktails on my own private islands. 

From tele-medicine, to skying with patients in route to your facility, technology is making things easier for patient care. I guess we will just have to wait and see what comes down the pipe next! Stay tuned