Over the past few decades—with the rise of the internet, the expansion of the middle class, and an aging American population—the healthcare industry has been forced to make technological advancements at an accelerated speed. One significant development has been in IT infrastructure with the adoption of electronic health records (EHR), making it important for nursing home teams to learn electronic health records best practices.
Moving away from traditional paper documentation to digitized, computer-based nursing home software has allowed long term care facilities to manage resident care plans better and raise compliance levels, thus improving the safety, quality, and efficiency in long term care facilities.
For any long term care software to be effective, though, it must have a set of essential features that cover the electronic health records best practices. Therefore, LTC software needs to be multi-functional with clear guidelines to include:
- A comprehensive record of a resident’s medical history, medication, treatment plans, allergies, and test results.
- Access to evidence-based tools, like point of care, so healthcare professionals can make accurate clinical decisions.
- An automated and streamlined workflow to improve efficiency and the quality of care.
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8 Core Functions of EHR Best Practices
In 2003, the Department of Health and Human Services commissioned the Institute of Medicine Committee (IOM) to define an EHR system’s essential care, delivery-related capabilities. The study provides a “functional model of an EHR system to assist providers in acquiring and vendors in developing software.” The IOM report organized the eight core functions of EHR best practices into the following categories:
- Health Information and Data – Long term care EHR needs to collect clinical resident data to make informed decisions during treatment. A lack of information will lead to poor quality and inefficient care causing medical errors and fatalities. Effective nursing computer software will have a built-in point of care function that allows medical staff to view and access important information like diagnoses, medication, allergies, and clinical narratives, as and when needed. Therefore, resident treatment is tailored to meet the real-time needs of the resident.
- Results Management – Computerized results improve the quality of care as electronic data is accessed more quickly and whenever needed. Reducing the lag time of finding resident data increases the efficiency of care and resident safety as medical staff can identify and treat medical problems quicker. They can also detect changes in conditions more quickly, so follow-up treatment is more manageable.
- Order Entry/Order Management – Computerized physician order entries generate automatic orders, monitor for duplicate orders, and reduce the time to fill orders. These electronic health records best practices help eliminate illegible handwriting, which improves workflow and decreases lost orders and ambiguities, thus enhancing the speed of completed orders.
- Decision Support Management – Clinical decision support can enhance a facility’s clinical performance in drug prescriptions, diagnosis, and detecting adverse events. Pop-up reminders and prompts are beneficial for medication administration to access critical information to reduce medication errors.
- Electronic Communication and Connectivity – Effective communication between healthcare professionals is imperative when coordinating care plans. Resident data sharing is essential in long term care as residents often have multiple illnesses. Therefore, healthcare professionals must share clinical information to allow greater care continuity.
- Resident Support – Resident support education is beneficial for people with chronic conditions. Giving residents access to educational materials gives them the independence to self-test with home-monitoring equipment, therefore self-managing their chronic conditions.
- Administrative Processes – Electronic scheduling has improved efficiency, communication, and service in managerial areas like hospital admissions, inpatient and outpatient procedures, and billing claims. The improved communication can identify, authorize and approve eligible residents for billing claims, thus decreasing delays and confusion.
- Reporting and Population Health – To improve community health, an efficient long term care EHR should store and transmit clinical data between the facility and public health organizations. Having key performance indicators on a dashboard allows physicians to view resident information, thus providing relevant data whenever needed.
The Impact of EHR in Nursing Practice
It is becoming more common for long term care facilities to use long term care EHR in recent times. This has changed the dynamics in facilities, with a strong impact of EHR in nursing practice. However, while nursing computer software is actively used throughout a facility, the transition from paper-based charting to EHRs has not always been smooth.
Learning to use long term care software can be daunting for less tech-savvy nurses, especially with multiple devices. There may be instances when nurses are not giving their full attention to residents because they are either focusing on the computer, inputting information, or looking for the right charts, all of which impact the quality of care. Nurses must adopt electronic health records best practices to provide better care in such circumstances.
Simple solutions—like giving residents their undivided attention during key moments, making eye contact when discussing sensitive issues, and encouraging active participation by showing data to residents—will improve resident interaction. And creating a patient-centered environment should always be the priority.
Other electronic health records best practices include offering EHR patient portals to improve patient engagement. However, few healthcare systems actually provide this; only fifteen to thirty percent of healthcare systems offer patient portals in America. Research into EHR best practices suggests that facilities should first outline how nurses can improve the transition process from paper-form to electronic. Valuable resources, like the Health IT Playbook, provide guidelines for successful EHR implementation and improving nursing practices in EHR.
Implementing Successful Electronic Health Records Best Practices
While it is important to understand electronic health records best practices, it is equally important to provide sufficient staff training so everyone using the software can maximize its capabilities. Of course, staff members use different functions of LTC software based on their role and responsibilities. Therefore, it is unnecessary to train every staff member to use every part.
Instead, when facilities integrate long term care software, they should identify the “super-users” in the facility. These are tech-savvy staff members who are keen and fast learners, but most importantly, they have the right attitude and patience to teach and aid others in using the nursing computer software.
Other team members should only be trained to use the essential functions they need to perform their job. This will improve the efficiency of facilities and help them avoid overloading staff members with excessive training. Meanwhile, “super-users” should on hand for when specific problems arise.