Quality Data And Documentation In The Electronic Health Record Research Paper Examples

Type of paper: Research Paper

Topic: Nursing, System, Information, Medicine, Health, Hospital, Record, Quality

Pages: 8

Words: 2200

Published: 2020/11/12

Electronic health data record systems refer to measures put in place for creating database, securing it, and accessing it in a health organization. The systems enable hospitals to store, retrieve, and share detailed information about a patient that can be used by any health provider authorized by the hospital (Jones, Koppel, and Ridgely, 2011). The systems also enable health providers to provide safer, more effective, in a more efficient manner care than it could have been, had they used paper-based system. It is a milestone achieved in most health centers today and is viewed as a tremendous progress of health care services around the world.
The quality of Electronic health data record system adopted by an institution is vital to the progress of that particular institution. Every institution has their distinct system that suits their circumstances and the kind of health care services they provide (Jones, Koppel, and Ridgely, 2011). However, the selection of the system is almost the same across institutions. The criteria used in the selection include:

The potential of the system to integrate with outpatient care

Availability of technical support, before, during, and even after installation of the system.
The system’s capability to be customized extensively.
Availability of upgrade materials that will help the institution to achieve meaningful use guidelines.
Functions of an Electronic Health Data Record Systems
Electronic health data record systems have over 24 functions related to health matters in a hospital at an average level. The functions range from clinical documentation, test, and imaging results, computerized physician order entry to decision-making (Jha, Desroches, and Campbell, 2009). Several institutions choose the model that will suit the kind of service they provide. The adopted system’s main function would then be to help hospitals achieve their institutional objectives. For instance, I have discovered that hospitals like New York –Presbyterian hospital is no longer scanning paper consent forms with patient signatures into their database. The hospital instead is using signature pads to enter digital signatures into their electronic consent templates. The patients are simply required to sign the signature pads, which are then recorded electronically in the medical record.

Electronic Health Data Record Systems Implementation

Every hospital has its own intensive and length program of planning, developing, and implementing their electronic health data record system. The plan involves system’s customization, the care process redesign to support use of the system, and user training. During implementation, the system is connected to an office-based version that is integrated with the whole hospital system (Jha, Desroches, and Campbell, 2009). The office-based model is used by physicians to share, modify, and record patient’s information in good time. A hospital can also decide to connect the system to outpatient records; however, I think that this will face stiff opposition from the outpatients and providers of the service.
Implementation also involves fixing and connecting of portals that provide internet access to their records. Others will use such devices as CD-ROM or flash disks to give patients records of their information being kept by the hospital. The portals will help patients to book appointments with physicians; view their medical results and request for electronic prescription. It helps them also to have discussions about their health with physician without necessarily physically visiting the hospital. One of the hospitals that have used this model effectively is Geisinger’s hospital portal (Zlabek, Wickus, and Mathiason, 2011). The portal is visited by over 155,000 people, which are almost one-third of patients. The strategy used in implementing this system is through discussion with the patients during their hospital visits, television, and print media advertisement.

Challenges Facing Implementation of Electronic Health Data Record Systems

There are various challenges that inhibit proper implementation of the Electronic health data record systems in health institutions. These challenges in turn affect the quality of electronic data storage. Some of these challenges include:

Achieving Physician and Staff buy-in

Jones, Koppel, and Ridgely (2011) argue that it is difficult to convince physicians and other health providers about the viability of a system they are not used to. Their fear is concerned with the resultant changes that the electronic record will bring to their day-to-day activities. Some users of this system are apprehensive of the fact that they may lose their jobs due to redundancy. It also has to get health officers conversant with electronic data recording so as to implement the practice in the workplace.

Performance Improvement

The major challenge here is how to streamline the new processes while improving its quality and efficiency. The system needs to be standardized in all departments so as, not to alienate physicians against other users. This is the only way the system can have maximum performance rate and improvement capabilities.

Using EHRs for Performance Reporting

Poorly trained workforce will have difficulties in implementing the electronic model for the first time when it is installed. The main area of concern will be to integrate free text fields and reporting requirement (Zlabek, Wickus, and Mathiason, 2011). Hospitals that have adopted this system have reported having various mismatches between the reporting requirement and data storage format. This has forced them to adopt data abstraction and manual translation measure to curb any effect that may arise from this challenge. Untrained users will experience delays in recording data and updating the same, which amounts to non-compliance with the electronic data recording standards.

Cost and Timing

Finally, the hospitals will experience challenges in sustaining this system. Adopting such a system is very expensive for any health institution especially when there are no government subsidies. The hospitals, therefore, have to develop strategies to contain, manage, update, and sustain the system in a cost-effective manner (Jones, Koppel, and Ridgely, 2011).

Strategies for handling the Challenges in the Electronic Health Data record Systems.

It is obvious that there are various challenges facing the transition to the new electronic health data recording system. Nonetheless, there measures to address most of these challenges and progress in the implementation of the system. Some of these measures include:

Strong Leaders Who Are Forceful and Realistic

I think that it is imperative that these institutions deploy focused departmental leaders to roll out the program. These leaders are critical in convincing other members of staff to buy into the idea and promote it even further. The leaders will also be responsible for enforcing the policy and holding any staff member who deviate accountable (Jha, Desroches, and Campbell, 2009). They should not tolerate resistant behavior and ultimately ensure that the policy is implemented. If the need be, they will have to fire those people who attempt to derail the transition to pass out a message that the policy is there to stay. Failure to implement the process should never be an option.

Involve Clinical Staff in Designing and Implementing the System

Secondly all users of the new system especially physicians must be involved in designing and implementing the system. This strategy will give the process legitimacy and support from the onset. The staff should be involved especially during customization stage where little expertise is needed (Jones, Koppel, and Ridgely, 2011). The method will make staff understand that their opinion and any input matters. It will also create a sense of ownership of the whole project.

Invest Heavily in and Require Training

The system requires extensive training to all personnel that will use it. The training should be extended to all administrative staff as well as physicians. Massive investment should, therefore, be invested heavily to ensure that external expertise impart their know-how to the internal structure. Zlabek, Wickus, and Mathiason (2011) assert that the training must be a long-term plan that will bring productivity to the organization. Short-term training may not take care of future changes to the system. Hence updating the system will be a problem. The staff will be able to train the entire community, and the patients will be able to access the service using the portals. The training should not be voluntary. Instead it must be compulsory, and all staff members must attend training sessions. They must sit for a proficiency test so as to be able to access the system.

Use the System to Aggregate Performance Data

Hospitals must use the electronic data storage mechanism to retrieve data about achievement by senior management, quality oversight committee, executive teams. The reports retrieved from this method are difficult to manipulate and may also be useful to hospitals in benchmarking its progress. Higher-level analysis will be achieved through electronic recording through export data by exporting data from the electronic records (Jha, Desroches, and Campbell, 2009).

Involve Quality Improvement staff in Developing and Updating the system

Hospitals can integrate tracking of information to promote external reporting requirement. They thus need to include quality improvement and accreditation of its system. Accreditation will be possible if personnel in the selection, design, and development of the system (Zlabek, Wickus, and Mathiason, 2011). The personnel will ensure that all alignments are done in accordance with existing best practices that make the records accessible. The partnership between the staff and experts is necessary for developing the update system.

Keep to Implementation Plan and Schedule

The major challenge in such a system is to stick to the implementation timelines. All stakeholders must create and stick to an implementation timeline so as to remain in schedule. Sticking to the schedule will manage the budget to avoid over expenses. The executive must take responsibility in ensuring that the plan is going as intended and planned.

Impact of the System on Quality of Health Care

Electronic health data record system provides any organization with essential benefits that help it to succeed and develop. Jones, Koppel, and Ridgely (2011) posit that the main benefit is to enhance the ability of the hospital to analyze performance data and identify areas of problems. These measures will help the management to introduce quality improvement efforts by identifying changes for process redesign. Electronic health data record systems will enable the users to customize data queries depending on various parameters. Quality assurers, departmental heads, improvement experts, and physicians must be able to question the system autonomously to explore the system’s improvement.
Secondly, the management must always undertake performance reporting and accountability. This process must be non-negotiable and must be done hand in hand with quality reporting programs (Jha, Desroches, and Campbell, 2009). The idea behind this is to develop performance reports, which are benchmarked at all, times. The report will involve physician’s data, departments within the hospital, and the mechanism to share this data across the board. The information recorded will help the board of directors, executives, and even management to promote accountability within the hospital. Accountability is critical, as it will help the hospital seal all loopholes through which there would be embezzlement of funds.
The third benefit that an organization accrues in implementing the system is improved communication within all its structures. Electronic health data record systems help in enhancing faster and accurate information. Patient’s details such as their medication, sicknesses, and medical records are accessed easily (Jones, Koppel, and Ridgely, 2011). The hospital will also be able to regulate who accesses this information using information access authorization policy. This information is key, and it can, for instance, inform physicians about the medical condition of a patient in case of readmission to the hospital. Managing this information properly will also lead to improved patient safety. It will be easier for physicians to administer drugs, avoid allergy conflict, and human error in during a patient’s treatment.
The records will help the hospital to ensure that patients are getting proper medication. This will save the hospital from the costs that may otherwise have been incurred in medical negligence cases. The physicians will also have been cushioned against unnecessary court cases that may distract them from providing services and which also threaten their career (Jones, Koppel, and Ridgely, 2011).
Finally, electronic health data record systems ensure there is more time allocated for patient care and quality improvement. Easy access of patient’s medical information improves the quality of service provided to them (Zlabek, Wickus, and Mathiason, 2011). At the same time, this information will save a lot of time for physicians who can easily access it at a designated point. The physicians will not have to return records after using them. They also do not have to check countless document in archives just to get one file that was kept there long time ago. However, I agree with other analysts who suggest that this process does not save any time. In fact, they see it as more time consuming than the paper based system. They claim to spend more time in documenting these records than they perform their duties at work (Zlabek, Wickus, and Mathiason, 2011). They propose, therefore, that there should be people assigned this role so that it is not to be carried out by physicians and clinicians. Further, having everyone documenting information in the electronic records may lead to inconsistency and lack of accountability about who exactly posted the records.


Electronic health data record systems have become an essential component in health care system around the world. The system is intended to promote healthcare quality by documenting all patients' information in the electronic data records accurately. It is also capable of improving efficiency and patient safety. Although this system has its own inherent challenges, the same can be handled with little efforts. The benefits that the system brings to the hospital by far outnumber the challenges to be surmounted. Policy makers in hospitals that have not adopted this mechanism need to start thinking about this area. Many lessons can be learned from those institutions that have already implemented the system.


Jha, C. M., Desroches, E. G., and Campbell, D. (2009). Use of Electronic Health Records in U.S.
Hospitals, New England Journal of Medicine, 360(16), 1628–38.
Jones, S., Koppel, R., and Ridgely, S. (2011). Guide to Reducing Unintended Consequences of
Electronic Health Records. Rockville, Md., Agency for Healthcare Research and Quality.
Zlabek, A., Wickus, J., and Mathiason, A. (2011). Early Cost and Safety Benefits of an Inpatient
Electronic Health Record, Journal of the American Medical Informatics Association, 18(2), 169–72.

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