Electronic care records will create single, standardised records for NHS patients in England. This will ensure that the fullest clinical picture is available to all
Ros Moore, RNT, RN, is chief nursing officer for Scotland; Gill Stonham, RN, is head of strategic alignment and knowledge management at NHS Connecting for Health.
Moore R, Stonham G (2010) Electronic care records give nurses access to information that can transform patient care. Nursing Times; 106: 13, early online publication.
The NHS Care Records Service is in the process of developing electronic care records for the NHS in England. This article examines the background to electronic records and how they can support and improve everyday nursing practice.
Keywords Electronic care records, Information technology, standardised records
- This article has been double-blind peer reviewed
- Electronic care records will offer immediate access to unambiguous and up to date clinical information.
- Care plans will reflect current evidence and best practice.
- The introduction of ECRs will help to ensure that clinical care is underpinned by large scale research.
In Modernising Nursing Careers - Setting the Direction (Department of Health, 2006), the chief nursing officer for England argued that nursing must change to meet the complex global challenges facing the NHS. It is widely recognised that greater use of information technology would empower nurses to meet these challenges, particularly when set against the current backdrop of quality, productivity, value for money and changing public expectations.
Although nurses have tended to be slow adopters of information technology (National Nursing Research Unit, 2009), the introduction of local IT systems and widespread use of products and services from the National Programme for IT in England means that it is rapidly becoming integral to every aspect of their working lives.
While most will be involved in using only some of these technologies, all nurses will be involved in using the electronic care record (ECR), which is currently being developed and implemented throughout the NHS in England.
The ECR has been identified as one of the key factors in enabling the NHS to improve the quality of patient care and support the transformation of clinical services (DH, 2008). It would achieve this by:
- Providing healthcare professionals with a tool for clinical practice that gives them access to accurate and up to date information about patients;
- Supporting current and ongoing clinical management;
- Establishing an integrated record of the care given by NHS organisations as patients move between primary, acute and tertiary care;
- Providing a rich source of reliable and valid information to support research and a whole range of quality and performance monitoring systems - often called the “secondary uses” (Brennan, 2007).
Responsibility for developing and implementing the ECR currently lies with NHS Connecting for Health, the strategic health authorities and NHS organisations. To ensure the ECR fulfils its purpose, NHS Connecting for Health is charged with providing the national infrastructure, technical standards and clinical terminology standards that would ensure compatibility between systems.
Providing it is used to maximum effect, the ECR has the potential to support safe, timely and high quality care with clear health outcomes and to tackle poor record keeping practices (Saranto and Kinnunen, 2009). It could also enhance the ability of individual nurses to audit, research and innovate.
Increasingly, nurses need to work in and across a range of settings, both as leaders and members of multidisciplinary teams, ensuring that care is organised and integrated around patients’ needs through individualised pathways. Key to this is the ability to share well structured and unambiguous clinical and social information that supports the underlying assessment, planning and workflow of patients’ care pathways. The main source of this information is the nursing record.
Bellack et al (1992) argued that a comprehensive assessment is essential to accurate nursing diagnosis and the design and implementation of cost effective interventions that improve health outcomes and promote patient welfare.
Electronic systems enable healthcare professionals to agree the content of initial and specialised assessments based on existing evidence, guidelines and policy. Once agreed, standardised documentation can be developed and made available across health communities and clinical networks. This in turn allows mandatory elements of data collection to be captured as part of the routine workflow.
Building on the use of standardised assessment, electronic records can also support evidence based pre-constructed care plans built from re-usable “building blocks” of care such as the management of acute pain, the management of intravenous lines.
Standardising terminology encourages nurses to develop care plans from bland statements of intent to unambiguous, prescriptive and Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) coded actions. For example, “calculate the fluid intake” needs of the patient rather than “ensure adequate fluid intake”, offers practitioners the opportunity to base care on structured, actionable knowledge, the impact of which is measurable, quantifiable and can be adjusted in response to a patient’s condition.
Using an ECR system that can be shared across the healthcare team, irrespective of location, enables coherent and consistent care planning across the patient pathway. It can also support the bundling together of appropriate interventions, the inclusion of quality indicators and a prospective approach to discharge planning, all of which are associated with high quality care.
Incorporating all patient records into one electronic format, rather than a collection of separate paper records, should promote communication between teams, and allow decision making based on real time data, with the fullest clinical picture available to all.
Nurses are ideally placed to have a significant impact on patients’ wellbeing by enhancing their understanding of their health status and their ability to contribute to self care. The ECR will support this role in a number of ways.
Consistency in approach and information: shared records allow nurses to personalise information for each patient, and make it accessible at all points along the care pathway. This increases patients’ confidence in the quality of information and education they receive and ensures consistent messages from different healthcare professionals.
Empowering patients: holding the clinical record electronically can allow planned interventions, such as retinal photography, to be scheduled routinely, or key results or health markers to be viewed graphically as a time line. Viewing and using clinical information in this way gives nurses an opportunity to influence and lead on prevention and health promotion.
Education is also a significant part of nurses’ role in supporting patients in their own homes. The ECR is part of a wider system that enables community nurses to consult with other practitioners and share monitoring and reporting on emerging problems and issues. Remote consultation can easily be supported through simple email and text services or by sophisticated tele-monitoring equipment connected to centrally located nurses and other healthcare professionals.
Leading and managing
Frontline nurses have a responsibility to ensure that resources are used in a way that maximises the safety, health and wellbeing of their patients, optimises productivity and delivers value for money. Bringing this set of challenges together within the current financial and performance framework is likely to be difficult to achieve unless nurses and other clinical professionals exploit some of the opportunities offered by the ECR.
Managing across care pathways
Very often patient outcomes depend critically on how effectively the care pathway is managed. A redesigned pathway supported by electronic records with standardised clinical documentation will support comprehensive, multidisciplinary assessment of illness severity. Identifying comorbidities, disabilities and social needs is the most likely way to achieve faster clinical decision making, reduced readmissions, reduced mortality and to secure an overall improvement in patient experience.
Patient handover between staff at different points in the system is always an area of potential risk (Patterson et al, 2004). However, this is exacerbated in a paper based system in which information is frequently rewritten and re-interpreted. The ECR allows information to be electronically collated, structured and communicated; Heart of England Foundation Trust has reported significant benefits both for staff and patients.
With electronic records, any changes to clinical documentation and recordkeeping can be managed centrally, with the removal of earlier versions. Managing clinical documentation in this way not only removes the risk of multiple, modified versions, but also improves the overall standard, assurance and governance of all clinical documentation. Consolidation of the electronic record also supports more productive use of nursing time.
Researching and improving practice
Nurses have a duty to participate in or lead research and audit that develops the profession’s knowledge base, informs best practice and supports quality improvement.
Taking information from paper based records is time consuming, inconsistent, often lacking in governance and frequently incomplete. By using structured documentation and coded data capture within an ECR, the ability to collate and report against patient outcomes as well as quality and performance indicators is simplified, repeatable and manageable across large cohorts of patients. In addition, access to large amounts of data increases the value of research and makes discovery and comparison much more robust and significant.
While this article has focused on the advantages of the ECR, eminent researchers such as Greenhalgh et al (2009) and Urquhart and Currell (2005) have advised caution. They point to the paucity of good evidence, potential disadvantages and a range of complex issues such as data standardsthat can reduce their efficacy. Nonetheless, many NHS trusts are already using electronic records and managing such issues as they arise. They recognise that a standardised, legible and objective record that is accessible to patients and clinicians is the minimum requirement for safe and effective healthcare.
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