'Information systems are now a fundamental part of care'
Jeremy Hunt, secretary of state for health, gave a speech in January in which he challenged the NHS to go paperless by 2018 to save billions, improve services and help meet the challenges of an ageing population.
This ambition means that, whether a patient is being seen in primary care, hospital or a care home, the professionals involved can see the patient’s history at the touch of a button and share crucial information easily.
This will be a challenge for many nurses and other practitioners. In some settings, little has changed in the way we document care and access information in the decades I have been nursing.
However, in some areas, we are starting to see the emergence of new technologies that have the potential to make a major difference for staff. See, for example, the mobile health worker project featured on page 16.
If, as a profession, we are serious about using electronic records and information to help us deliver better, more efficient care, we need a wider professional debate about how to achieve that goal. This debate could cover: what standards need to be in place so we can share information? How can we record information that matters to improve care and reduce harm in a way that patients understand? How do we record information once - at the point of care - then use it many times for outcome assessment, audit, service improvement and research?
Nurses need to take professional responsibility for the information we record and where and how we record it. We need to understand the balance between sharing information and protecting information about patients. We need to acknowledge that records rightly belong to patients and that we are contributing to their records.
On top of all of this, it’s no longer about nursing records. They are the patients’ records and we need to understand the shift in professional attitudes required. Information is not a by-product of care but a fundamental part of it.
All these issues will require leadership at all levels. Using information and information systems is no longer optional in nursing and midwifery work; in a modern world, it is fundamental to how we do things.
Embracing the brave new world will take courage. Yet we should take solace from the fact we have already started this journey. In many areas of practice, we have coped with an evolution of technological innovation already.
So what do we need to do? We need to think carefully about the care we deliver and have the commitment and courage to adapt and change.
We need to consider record keeping and how we share information in records with our patients. We need to understand the importance of transparency and good-quality information. It is not going to be an easy journey but it is one worth travelling.
Anne Cooper is National Clinical lead for Nursing, Department of Health informatics directorate
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