Case Study: Nursing Documentation in the Electronic Age
Incorporating Workflow in Patient Care Technologies
Workflow is the sequential action or execution of tasks constituting a work process (McGonigle & Mastrain, 2018). This concept has influenced or altered the clinical environment to create a more responsive and stable workplace (McGonigle & Mastrain, 2018). In conjunction with health care technology, this transition facilitates nurses’ workflow and optimizes patient care and outcomes (McGonigle & Mastrain, 2018). By supplying patients with medical records, electronic documentation systems eliminate medical errors and increase quality, efficiency, and safety (Zaman et al., 2021). It is estimated that nurses devote roughly 25% of their time to documentation (Zaman et al., 2021). Since the electronic system analyzes care, communication, and planning depending on a patient’s health status or disease, nurses must be proficient in providing exemplary patient care (Zaman et al., 2021). According to the results of a study conducted in 2021, nurses who possess broad computer skills related to the usability of electronic documentation systems have a good attitude toward adopting new technologies in the workplace (Zaman et al., 2021). It is essential to instill faith in electronic systems to implement lessons or classes on computer system fundamentals (Zaman et al., 2021). In the survey, a nurse commented, “It would be beneficial to understand the basic program before EMR training” (Zaman et al., 2021). In turn, this would facilitate the implementation of new EMR systems. Training in electronic systems has a significant impact on the nurses’ perceptions of usability (Zaman et al., 2021). In addition to training, everyday interaction with the system increases the perception of the system’s use (Zaman et al., 2021). Positive Results Using a workstation on wheels (WOW) for bedside charting affects the relationship between patients and healthcare professionals (Drobny, 2017). Drobny describes a personal encounter with a patient involving electronic documentation (2017). While side-by-side with a patient, they proceeded through the electronic health record-based initial assessment and answered the questions cooperatively (2017). The patient began to ask questions, enhancing his health literacy and fostering a relationship of trust (2017). This participation enabled greater patient-centered care while acquiring accurate health data (Drobny, 2017). Using WOW systems to document the assessment process enhances the patient-provider connection, health literacy, and quality of care. In addition to improving the quality of care, technology can also improve the precision and efficiency of care procedures while decreasing errors or dangers (McCarthy et al., 2018). These tools can monitor and track poor outcomes and reduce medication errors and harmful drug interactions (McCarthy et al., 2018). Kossman and Scheidenhelm discovered that electronic health records (her) increased patient safety by delivering vital “alerts” regarding data inputs, allergies, and medication errors (McCarthy et al., 2021). Enhancement of Prompt Care Does this, in turn, increase the time spent with patients, thereby enhancing the quality of care? In a research conducted by Banner & Olney, this identical issue was posed (2009). They discovered that after installation, nurses spent much more time on paperwork (Banner & Olney, 2009). As the future of documentation functions advances and manual entry decreases, time spent engaging with systems decreases (Banner & Olney, 2009). In a comparable study, Bosman et al. discovered that the adoption of a computerized system reduced nurses’ documentation time by 30 percent (Banner & Olney, 2009). This gave nurses more time to care for patients. As documentation time decreased, ICU nurses could boost their direct patient care from 31 percent to 40 percent.
Case Study: Institute of Medicine Report Analysis : Information Management and Patient Care Technologies
Bettering the Current Healthcare System
There is more work to be done on the American health care system. Over two decades have passed since the Institute of Medicine revealed that around 98,000 patients die annually due to medical errors (Haskins, 2019). There is little doubt that safety and patient-centered care have established the dominant framework with campaigns, “challenges,” and implementations throughout the country (Haskins, 2019). These include “Safe Surgery Saves Lives,” the implementation of new patient handoff reports, reducing hospital-acquired infections, and the Patient Protection and Affordable Care Act (Haskins, 2019). There is always room for expansion.
Regarding the future of healthcare, experts anticipate increased patient and family engagement in safety and health equity (Haskins, 2019). In contemporary times, health equity is crucial. This guarantees that patients receive the care they need, when they need it, regardless of their gender, race, geography, or socioeconomic situation (Dawes, 2016). Care will be more accessible, cost-effective, and patient-centered if these challenges are addressed within the healthcare system (Dawes, 2016). The Six Goals As a result of this extraordinary value that the IOM published in 1999 to enhance healthcare, six purposes or goals have been formed. According to the book Crossing the Quality Chasm, they are safe, efficient, patient-centered, timely, and equitable (IOM, 2001, pg 39-40). Safe can be defined as avoiding injuries; effective as providing service based on science and avoiding underuse and overuse; patient-centered as providing care that is respectful and responsive to the individual; timely as reducing wait times and potentially harmful delays; efficient as avoiding waste, such as equipment and supplies; and equitable as care that does not vary based on demographics such as gender and ethnicity (IOM, 2001, pg 39-40).
The United States has taken substantial protocol measures to fulfill these ongoing objectives. In acute care settings, the 100,000 Lives Campaign has implemented innovative patient safety strategies (Baehrend, 2016). This effort is dedicated to decreasing unintentional patient fatalities by providing hospitals with no-cost tools and counseling (Baehrend, 2016). These measures included implementing fast response teams, the reconciliation of medications, and the prevention of hospital-acquired infections caused by central lines, surgical sites, and ventilator-associated pneumonia (Baehrend, 2016). The majority of these procedures are still performed in hospitals today. In terms of timely, efficient, and fair care, the development of the Affordable Care Act (ACA) increased Americans’ health care coverage and, in turn, improved patient safety (Haskins, 2019). According to recent figures, 39 million Americans now have free access to preventive medical care (Stasha, 2021). The Affordable Care Act has enabled low-income individuals to obtain decent treatment without incurring considerable debt and before a disease becomes incurable (Stasha, 2021). This enables individuals to utilize primary care services, increasing the population’s general health, enhancing patient outcomes, and decreasing per capita care costs (Taylor et al., 2020). The basic framework of health information technologies and the individual’s participation in meeting their healthcare requirements has been patient-centered care.
Regarding the individual, they desire to be informed about their treatment, including diagnosis, prognosis, and what can be done to alter the results, in a language they can comprehend (IOM, 2001, pg 50). To make their healthcare more effective and comfortable, patients desire physical comfort, emotional support, and family and friend involvement (IOM, 2001, pg 50). They improve patient outcomes and desire to participate in change through increased patient involvement and patient-centeredness (IOM, 2001, pg 50). Health Care and Technology: The United States has achieved significant technological advancements since these initial IOM studies were published in 1999. Its involvement in healthcare has significantly advanced these six goals. Healthcare technologies aim to increase patient safety, quality, and outcomes (McGonigle & Mastrian, 2018). Electronic health records and clinical decision support systems facilitate precise diagnoses and suitable treatments (McGonigle & Mastrian, 2018). These programs prompt warnings and detect adverse events, mistakes, adverse drug reactions, and hospital-acquired infections (McGonigle& Mastrian, 2018). In addition, wireless patient monitoring, telemetry, and physician alarms have been established (McGonigle & Mastrian, 2018). With the drive to improve patient care, health technology will continue to expand.
Baehrend, J. (2016). 100,000 Lives Campaign: Ten Years Later. http://www.ihi.org/communities/blogs/100000-lives-campaign-ten-years-later.
Committee on Quality of Health Care in America, & Institute of Medicine. (2001). Crossing the Quality Chasm : A New Health System for the 21st Century. National Academies Press. (39-60).
Dawes, D. (2016, December 5). Why Health Equity Matters in an Era of Health Care Transformation. Association of American Medical Colleges. https://www.aamc.org/news-insights/insights/why-health-equity-matters-era-health-care-transformation.
Haskins, J. (2019, June 6). 20 years of patient safety. Association of American Medical Colleges. https://www.aamc.org/news-insights/20-years-patient-safety.
McGonigle, D., & Mastrian, K. (2018). Nursing informatics and the foundation of knowledge (4th ed.). Jones and Bartlett.
Stasha, S. (2021). 27+ Affordable Care Act Statistics and Facts). Policy Advice. https://policyadvice.net/insurance/insights/affordable-care-act-statistics/.
Taylor, E., Peikes, D., Geonnotti, K., McNellis, R., Genevro, J., & Meyers, D. (2020). Quality Improvement in Primary Care. Agency for Healthcare Research and Quality.