Reducing errors through electronic health records

This content origi­nally appeared in the Spring/​Summer 2020 issue (PDF) of The Washington Nurse magazine. See the full set of stories on long-term care.

As nurses, we recognize that long-term care is not merely a place people reside but also a status during their lives. While it is apparent that most people are in the care of others from birth to death, nurses especially focus on improving the outcomes for the patients, their families and the caregivers who reside within a long-term care paradigm.

I currently work as a nurse in an emergency room, focused on the acutely ill. A high percentage of our patients arrive from skilled nursing facilities, from adult family homes or from their own homes, where they may be cared for by family members or agency caregivers. It is very challenging to assess their needs as they frequently arrive without any details beyond their own recollection or those of emergency medical service responders. Medical histories, medication records and POLSTs (Physician Orders for Life-Sustaining Treatment) are frequently missing or absent from their records. If a family member accompanies, they sometimes have a copy of the durable power of attorney, but rarely is there a complete, up-to-date list of medications. Fortunately, pharmacy records are more likely to be in the patient’s database than most other information. Written, let alone oral (via phone), handoffs from other RNs via SBAR (Situation Background Assessment Recommendation) are very rare. The best skilled nursing facilities follow up later, but usually, if information is missing, we must call the caregivers for clarification. Some patients arrive without any information, even lacking the name of the facility from which they came. All of this complicates and delays treatment.

It is rare for anyone in the health care system not to have their medical information in electronic form. Access to the patient’s electronic health record should be available to those providing health care in appropriate settings. There are examples of such systems in place in other areas of the world. For example, Denmark has a centralized computer database accessible to 98% of primary care physicians, all hospital physicians and all pharmacists. Danish residents can gain access to their own records through a secure website. However, the country’s health care is run by the public sector. Finland and the Netherlands have over 95% of citizen records available. Canada and Australia have much greater geographic and cultural diversity of their residents, but both are making great strides. The National Health Service in the UK reportedly still has many platforms but is making progress toward a unified electronic health record system. Institutions of varying complexity could add elements to the chart based primarily on their needs and secondarily on their resources.

The federal government would be the appropriate leader to initiate a national electronic health records system. It would be a huge undertaking — of money and resources. One possible source of funding could be a tax on the pharmaceutical industry, especially since the database would potentially include up to 330 million patients. The centralized storage of records would require a valid and reliable design, created to reduce chances of hacking or being compromised. Limits on how the information could be accessed by industry and prohibitions of advertising on the platform would be necessary to ensure reliability, public buy-in and lack of bias for providers and consumers. Security, including adequate encryption, is vital and available using two-factor authentication.

In addition to information about health care provider visits and changes in medication records, it would be beneficial to include imaging, lab work, assessments and patient directives. All information could all be available and updated from any secured computer by a licensed health care professional using two-factor authentication.

There are many gains from such a system. A large complete record of all of us would be available wherever we travel or move in the U.S., making available:

1. Clear, concise directives by the patient or their legal representative.
2. Rapid access to the most recent data on the patient.
3. A complete, current medication list, including dosages.
4. The ability to quickly update the record for other health care providers.

The downside is cost and potential hacks to the system (minimized with two-factor authentication), and, politically, many people are worried about protecting their information and who has access to it.