NUR-514 Benchmark – Electronic Health Record Implementation Paper

NUR-514 Benchmark – Electronic Health Record Implementation Paper

An electronic health record (EHR) refers to an electronic form of the traditional patient’s medical file kept by the health provider over time. It contains information from administrative and clinical encounters between patients and their health providers during patient care. The EHR also supports other patient care-related activities through interfaces, such as evidence-based decision support, outcomes reporting, and quality management (Schopf et al., 2019). This paper aims to discuss components of designing and implementing the EHR, the professional, ethical, and regulatory standards that should be incorporated, and leadership skills needed for collaboration of the interprofessional teams.

Key Information Needed in the Database to Track Opportunities for Care Improvement

The EHR support providers make better decisions and improve patient care quality. It achieves this by improving the accuracy and clarity of medical information, which reduces the occurrence of medical errors (Schopf et al., 2019). The EHR also makes health data available and easily accessible, reduces duplication of services, reduces treatment delays, and empowers patients to make better health decisions. Patient information is needed in the EHR database to help identify opportunities for patient improvement. The key patient information includes demographics, current medical problems, past medical and surgical history, medications, vital signs, immunization history, progress notes, laboratory results, and imaging reports (Schopf et al., 2019). The information can predict a patient outcome which helps to provide appropriate interventions to achieve the best possible outcomes (Schopf et al., 2019). It can also identify risk factors for a disease or complications and guide providers to take prior preventive interventions.

Role Informatics Plays in the Ability to Capture This Data

Informatics deals with computational systems, particularly with systems that involve data storage and retrieval. The role of informatics in facilitating the capturing of the data in EHR databases includes providing tools with clinical and operational applications that help health organizations capture health information in EHRs to advance medical care (Aguirre et al., 2019). Informatics help organize patient data collected from a myriad of devices and systems such as electronic medical records, patient portals, health tracking devices, and diagnostic systems (Aguirre et al., 2019). Informatics captures the data from all these devices, which is usually in different formats, and converts it to a single format stored in the database. For instance, database management systems have programming interface applications that transmit connections between databases and are used to process complex health information across various platforms.