Improving Patient Outcome – Electronic Health Records Systems (EHRs)
The use of electronic health records (EHRs) is progressively viewed as a necessary component within healthcare, enabling healthcare organizations, healthcare providers, and nursing professionals to manage and document the quality of care provided to patients. To further that goal, healthcare organizations are leveraging EHRs to develop clinical decision support (CDS) systems to optimize patient outcomes. According to Lam, J. & Ng, O. (2017), EHRs and CDS systems can assist clinicians with decision-making support based on relevant content that is available at the point of utilization. Examples would include drug-dose calculators, drug interaction screenings, and evidence-based order sets and care planning.
The IOM (2012) encourages the use of EHRs for its prospective of delivering secure systems of care and restraining costs through improvement in the provision of care. Yanamadala et al. (2016) describe EHRs as being a prerequisite to coping with the demands of healthcare reform and evolving practice requirements.
Clinical Problem and Significance
The healthcare profession acknowledges that patient safety is an element of quality, but safety is also crucial to an organized and competent healthcare system. Patient safety aims to avoid adverse outcomes, while quality concerns the overall system of care delivery’s impact on outcomes and strategic goals. According to Bright et al.. (2012), “Healthcare modernization is best visualized if we compare how we were forty years ago and where we are today; the need for improvement has been the Driving force behind the evolution of computers in healthcare” (p. 36). The literature revealed that the past decade has seen an emphasis on harnessing technology to enhance and improve the efficiency and quality of the clinical process and the anticipated benefits to implementing EHRs include improved clinical outcomes, increased transparency, and improved patient engagement and assent. Patient care and the EHR have become a predominant focus in the development of new ideas and knowledge in healthcare technology. Varying components of the electronic health record are now being utilized with increasing frequency in healthcare organizations in an effort to enhance patient outcomes, improve the quality of care provided, and improve efficiencies. Despite the potential benefits of EHRs, implementation can be faced with a multitude of constraints such as cost, technical limitations, standardization limits, the behavior of end-users, and organizational constraints. Professional nurses require skills and a comprehensive knowledge base in order to utilize EHRs to their fullest capacity. According to Black et al.. (2012), the ability of nurses to acquire and use an EHR program quickly and professionally is believed to reduce facility costs for implementation, enhance patient care and safety, and improve patient quality outcomes.
Search Strategy
An extensive search of the literature from 2012 to January 2017 was performed using EBSCO Host, CINAHL, Cochrane Library, and Wolters Kluwer. Search strategies were specific to the database and included keywords that reflected electronic health records and outcomes. The CINAHL search included the terms: electronic health records, health informatics, patient safety indicators, information systems, healthcare quality, and patient safety indicators. When searching the EBSCO Host, Cochrane Library, and Wolters Kluwer, the key search words added were computerized patient records, hospital information systems, improved outcomes, and efficiency. Only full-text papers published in peer-reviewed journals were chosen for closer review, while editorials, discussions, and theoretical papers were excluded. Abstracts of all papers identified from the described search strategy were read and assessed by this author. Abstracts that were considered relevant to the research question were kept for further review. In the absence of an abstract, full-text papers were obtained and read. Reference lists of selected papers were closely examined to identify additional articles relevant to the research question.
Impact of Technology on Nursing Efficiency and Patient Outcomes
Nurses and physicians are the primary providers who benefit the most from the utilization of EHRs and CDS apart from their patients. The primary goal of EHRs is to deliver high-quality organized care by allowing members of the healthcare team to access a patient’s medical history whether they show up in the emergency department, urgent care clinic, or switch primary care providers without transporting their medical records. The EHR allows physicians and nurses to have simple and straightforward access to patient health information and data, allowing them to make expedient clinical decisions. Improvements in the application of quality measures are important for cost savings as well as outcomes. Medical errors, postoperative complications, and longer hospital stays are all factors that could lead to increased costs (Elnahal et al. (2013). The Institute of Medicine (2012) highlights that enhanced clinical process workflows partnered with the utilization of EHRs to support the delivery of care processes are one set of tools proposed to achieve optimal outcomes. At the same time, the Agency for Healthcare Research and Quality (AHRQ) has developed a set of indicators that can be used with hospital administrative data as a benchmark for inpatient quality (AHRQ, 2012). Current healthcare models of pay-for-performance, patient-centered medical home model, and accountability to care organizations provide a heightened sense of urgency to embrace technology in order to aggregate and report results in order to receive reimbursement.
Research Evidence
Studies utilized in this review had to report at least one of the following types of outcomes; overall patient length of stay (LOS), mortality, morbidity, untoward events, approach to healthcare focusing on preventative care, clinical studies, treatment protocols initiated or completed, and efficiency. Additional indicators included were patient satisfaction, cost-effectiveness, and acceptance by healthcare providers. The population sizes referenced within each study ranged from Finney Rutten et al.. 2014 study focusing on the patient’s perceptions of electronic medical records use and how they rated the quality of their care with n=7,390 record reviews and satisfaction surveys to an observational study conducted by Yanamadala et al.. in 2016 reviewing the impact of EHRs on mortality, readmissions and complications with n = 448,767 total records retrospectively reviewed. An appropriate statistical analysis was applied with multiple studies utilizing a relative-risk difference in differences analyses to determine the effect of EHR systems on the quality of care and patient outcomes. The difference-in-differences analyses combined pre-post and treatment–control comparisons.
Subjects of Study
Most of the articles utilized in this review were based on retrospective charts or data analysis, with one study utilizing blinded patient satisfaction surveys following inpatient admissions. The data presented in each of these articles represented a minimal risk to the subjects as no specific protected health information was disclosed. Specific information released pertained to gender, age, diagnosis, and outcomes but could not be linked to any specific patient or specialized population. Based on this review, it is this author’s belief that the probability and magnitude for harm or injury, including physical, psychological, social, or economic, occurring for study participants was minimal and that consent or waiver would not be required.
Analysis of Research
The literature revealed anticipated benefits to implementing EHRs, including improved clinical outcomes, increased transparency, and improved patient engagement and assent. The literature furthermore suggests that utilization of EHRs can enhance the efficiency with which that care is provided. The forward momentum to improve the overall quality of patient care while improving outcomes, decreasing readmissions, and decreasing mortality rates has led to the development of a variety of measures to evaluate quality. Ultimately the utilization of EHRs as a tool to improve outcomes, focus on quality, and minimize costs will require continued review.
Many of the studies identified their independent variables as being the level of EHR utilization, patient demographics, comorbidities, and medical or surgical groupings, while the dependent variables were mortality, readmissions, and complications. The overall trends noted in the studies that were reviewed indicated improved outcomes and shorter lengths of stay for post-surgical patients, lower mean estimated cost per discharge in the post-surgical patient, and lower readmission rates for the post-surgical patient population, while medical patients displayed lower mortality rates. A decrease in adverse patient safety incidents was noted across both the medical and surgical populations. Wright et al.. (2011) define an adverse event as an “unintended injury or complication, which results in disability at discharge, death or prolongation of hospital stay, and is caused by healthcare management (including omissions) rather the patient’s disease” (p. 192).
The strengths noted within the current studies reviewed were the population sizes, and that very specific patient populations were evaluated in both the post-surgical and medical patient groups. This author has concerns with the lack of standardization for ensuring data quality within any particular patient record, completeness of the medical record documentation, and the retrospective review of the record relying on secondary data versus primary data collection.
References
Agency for Healthcare Research and Quality. (2012). AHRQ Quality Indicators—Guide to Inpatient Quality Indicators: Quality of Care in Hospitals—Volume, Mortality, and Utilization. Revision 4.4. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ).
Black, A., Car, J., Pagliari, C., Anandan, C., Cresswell, K., Bokun, T. & McKinstry, B. (2012). The impact of eHealth on the quality and safety of healthcare: A systematic overview. PLoS Med 8(1): e1000387. https://doi.org/10.1371/journal.pmed.1000387
Bright, T., Wong, A., Dhurjati, R., Bristow, E., Bastain, L. & Lobach, D. (2012). Effect of clinical decision-support systems: a systemic review. Annals of Internal Medicine, 157(1), 29-43. doi 10.7326/0003-4819-157-1-201207030-00450
Elnahal, S., Joynt, K., Bristol, S. & Jha, A. (2013). Electronic health record functions differ between the best and worst hospitals. The American Journal of Managed Care, 17(4), 121-147.
Finney Rutten, L., Vieux, S., St Sauver, J., Arora, N., Moser, R., Beckjord, E.& Hesse, B. (2014). Patient perceptions of electronic medical records use and ratings of care quality. Patient-Related Outcome Measures, 5, 17–23. doi.org/10.2147/PROM.S58967
Institute of Medicine. (2012). Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: The National Academies Press.
Lam, J. & Ng, O. (2017). Monitoring clinical decision support in the electronic health record. American Journal of Health-System Pharmacy, 7(4), 1130-1133. doi: 10.2146/ajhp160819
Wright, A., Sittig, D., Ash, J., Bates, D., Feblowitz, J., Fraser, G. & Middleton, B. (2011). Governance for clinical decision support: Case studies and recommended practices from leading institutions. Journal of the American Medical Informatics Association, 18(2), 187- 194. doi: 10.1136/Jamia.2009.002030
Yanamadala, S., Morrison, D., Curtin, C., McDonald, K., & Hernandez-Boussard, T. (2016). Electronic Health Records and Quality of Care: An Observational Study Modeling Impact on Mortality, Readmissions, and Complications. Medicine, 95(19), e3332. http://doi.org/10.1097/MD.0000000000003332
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Due 5/16 at 5 pm EST
250 Words APA not including 1 reference All posts should be supported by a minimum of one scholarly resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.
Improving Patients Outcome
Identify a quality improvement topic you are interested in.
What is the role of the APRN in improving patient outcomes related to this topic?
Discuss benchmarks for monitoring improvement.
Consider causes of decreased patient outcomes related to this topic.
Discuss workforce challenges that may impact patient outcomes related to your topic.