You and your care team in the emergency room have just received an unconscious, air-flighted, car-accident victim. Yet even before she arrived, you had learned, in addition to the information about her new injuries provided by the paramedics and nurse aboard the helicopter, the name of her primary physician, the source of her insurance, that she was from a town 1,500 miles away, that her blood type was A positive, and that she was on an anticoagulant and had had a hip replacement six months ago after which she developed a deep vein thrombus. Sound far fetched? The technology to make this happen is with us today, and in some countries it is already a reality. The technology used in communicating the information in the scenario above included a healthcare smartcard and an electronic health record (See Table).
Electronic health records are designed to provide nationwide access to designated information compiled from data found in medical records created by various providers regardless of whether providers are in the same healthcare system, or as in the case of the accident victim described above, in a different system far from the patient's home. You are probably already familiar with at least some components that will be included in an electronic health record. Your agency may already be using computerized provider order entry (CPOE), or have implemented other computerized systems, such as a medication administration system. These components are all building blocks for a complete agency record that is labeled the electronic medical record (EMR) (See Table) (National Alliance for Health Information Technology, 2008) that is owned by the provider that has created it. In contrast, an electronic health record (EHR) (See Table) is created when information from records created by a variety of agencies that are under different ownership is made available to other healthcare providers within a network. The EHR allows those healthcare providers designated by the patient to obtain healthcare information related to past episodes of healthcare. It is hoped that such a record will eventually be a birth-to-death electronic healthcare record.
Sharing healthcare information between unrelated providers will probably start with the creation of a Regional Health Information Organization (RHIO) in which providers in the same area share information. This step involves the electronic exchange of health-related information between organizations in the same geographical area using agreed-upon standards, protocols, and other criteria (National Alliance for Health Information Technology, 2008). Eventually, the RHIOs will be combined into larger entities until all the healthcare providers are connected in a National Health Information Network (NHIN) throughout the United States. This network will provide access to patient-designated healthcare information for clinical decision making nationwide (United States Department of Health and Human Services, n.d.).
As you can imagine, there are many technical issues involved in creating the NHIN, including data security, data access, patient identification, and the ability for all systems to communicate with one another. Information technology specialists are currently addressing these issues. Additional issues that will affect nursing even more directly are the types of nursing data that will be included in electronic health records, and the terminologies used to convey this data.
In the past, and currently, nursing notes, unless used institutionally in infection control reports, quality improvement projects, or for legal issues, are filed upon patient discharge in medical records departments and then are generally ignored. They are never used in the writing of discharge summaries. Additionally, too often nursing documentation is only a record of compliance with the medical regimen, or other Joint Commission reporting requirements, such as the completion of the appropriate hair removal procedure for surgery patients, or the use of beta blockers during the perioperative period for patients who were using these medications prior to surgery (Joint Commission, 2008). Although it is necessary to record this information, this information is not representative of the knowledge that we as nurses have and use when providing care. In summary, when nursing notes are recorded in a paper record, most of the recorded information is stored in the medical records department, yet ignored. Only the data used to meet reporting requirements is actually used following patient discharge.
The advent of the electronic patient care record, however, is changing this equation. Increasingly data stored electronically will become available to identify patterns of health care provided and subsequent outcomes among large groups of people. In a well-designed, electronic system, the data in each patient’s record is stored, electronically, as separate pieces of information in what are called fields. These fields are named and can be visualized as being a part of a data table, with each column in the table being a field (see table). Data about an administered medication would actually be stored in several fields, including one field for the name of the medication, another field for the dosage, yet another for the route of administration, and other fields for the times and dates of administration. There might be an additional field for comments. This type of data structure for storage is a database. In an electronic database (see table), data found in the various fields can be retrieved for many patients at one time. For example, it is possible to easily retrieve each record in which the field of 'medical diagnosis' contains congestive heart failure, along with the ‘length of stay’ field for each patient having this diagnosis. It is not necessary to retrieve the entire record. Rather the information retrieved can be limited to data in these fields. This resulting aggregated data (see table) can be summarized and the average length of stay for this diagnosis computed. If the ‘date admitted’ field is also retrieved, one can analyze the data by date admitted. Any other piece of data that meets given criteria can also be retrieved and analyzed. The process of retrieving the data is called querying, and can involve very complex requests for information, such as, “Show me the final diagnosis-related groups for all patients who had gastrointestinal surgery in June of 2008, who were operated on in Operating Room # 5, who developed a post-operative infection, who had not received antibiotic prophylaxis, and whose length of stay exceeded 7.0 days.”
When data is used for purposes other than the original purpose for which it was collected, which in the case of patient records is for describing the patient care provided, it is called secondary data usage. Secondary data can easily be de-identified (see table). With electronic records, more de-identified data will be shared and analyzed at all levels. Decisions will be made about priorities and funding based on the knowledge gleaned from analyzing this data.
Today, nursing care data, beyond basic compliance data, is very seldom included in this data which is being stored electronically, despite studies demonstrating that including nursing problems improves the accuracy of costing healthcare and predicting outcomes (Welton, Halloran, & Zone-Smith, 2006). This means that if electronic healthcare documentation, whether part of an EMR or an EHR, contains no data about the decisions nurses make, such as decisions about nursing problems, independent intervention actions, and the resulting outcomes, nursing data will not be used in healthcare planning and priority selections. Nursing’s role in healthcare will remain invisible, and nursing’s potential contribution will not be considered in healthcare policy. We all know what our nursing role is, but we have not yet learned how to communicate it to others. It is not unusual, when one is very knowledgeable about a topic, in this case good nursing care, to subconsciously believe that all people, especially administrators, understand what good nursing care includes. We may find it hard to believe, but outside of physicians, who depend on us, few people really understand that nurses are the eyes and ears of ongoing patient assessment and that we make decisions every time we perform a procedure, give a medication, or provide another type of care. The reasoning behind decisions related to the performance of the procedure is not captured if we simply document that we have performed a specific procedure.
To date nursing has failed to acknowledge that the day in which patient data will be stored electronically is fast approaching and that this electronic data will be used for secondary analysis, resulting in decisions that affect all of healthcare. If nursing fails to get nursing care data in an electronic format, healthcare decisions will be made without nursing input, despite the findings that ignoring nursing data results in inaccurate reimbursements. (Welton et al., 2006). This causes reimbursements to be inaccurate with the result that they do not represent the actual cost to agencies of providing good nursing care. Lacking this data nursing cannot be represented in the revenue column, which decreases our value.
If nursing data is to be part of the data analyzed from electronic patient records, we, as nurses, need to make two decisions: First, we need to decide what data should be included in the electronic record, and secondly, we need to decide what terminology should be used to record this data so that the meaning of the data is clear and consistent. The Nursing Minimum Data Set, which lists data that needs to be collected for all patients, has been with us since 1985 (Thede, 2003). This data set includes nursing problems, nursing interventions, nursing outcomes, and nursing intensity. Considerable work has also been done in the area of developing nursing terminologies, yet very little of this work has been implemented in practice settings. Standardized terminologies that are recognized by the American Nurses Association (ANA), and that allow the collection of nursing data in a manner that makes the meaning of each term clear, have also been developed. These terminologies include the Omaha System; the Clinical Care Classification; the Perioperative Nursing Data Set; North American Nursing Diagnosis Association, Inc; Nursing Interventions Classification; Nursing Outcomes Classification; and the International Classification of Nursing Practice (See [Thede, 2006] for more information about these terminologies.). Unfortunately, there are not many agencies that have implemented the use of use any of these terminologies for electronic nursing documentation.
Because as nurses we are already plagued with more documentation requirements than we have time for, the thought of learning and implementing new terminologies suitable for use in electronic records is often seen as overwhelming. However, secondary data usage is going to be conducted at all levels: in your agency, regionally, nationally, and internationally. Decisions will be made based on these analyses and these decisions will affect our nursing practice. We in nursing are at a point where the ship is being loaded and getting ready to sail. Soon the ship will leave—will nursing be on board? The decision today is still in our hands, tomorrow it may not be.
Letter to the Editor by Baroni
Linda Thede, PhD, RN-BC
National Alliance for Health Information Technology. (2008, May 20). Health IT terms established. Retrieved July 13, 2008, from
Article published August 18, 2008