Digital Record Systems in Hospitals and Learning E-Health

Running head: DIGITAL HEALTH RECORDS
Application of digital record systems in hospitals and learning eHealth
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DIGITAL HEALTH RECORDS
Introduction
The transition of traditional paper-based health record systems to the digitized electronic
health record system is increasingly being adopted in many hospital settings. Electronic
health record systems (EHR) provide a patient-centered chart in real-time in the digital form.
This chart consists of the patient’s medical history, diagnosis and pharmacological approach
of treatment, laboratory tests and radiology results (Evans, 2016). This paper focuses on the
application of digital records in hospitals and the necessity of adopting ongoing learning
regarding eHealth and reflects on the personal and professional reflection of a registered
nurse, its evaluation, analysis and strategies of the practice.
Personal and professional self-reflection
The adoption of digital health record system provides scope to enhance the quality and
delivery of clinical care in hospital settings. It requires continuity of learning the various
updates in applying eHealth practices. The electronic health record systems provide an
accessible channel to store all the information of a patient in one place and are increasingly
being adopted by various physicians and hospitals (Samuels et al., 2015). It has reduced our
efforts to maintain paper-based documents and storing these details in a folder. As it reduces
the effort of paperwork, it seems like a great idea in the beginning. However, with practice
and experience, I realized that these digital records are not very reliable as self-documented
health records as they are relatively new and all of its types have not been worked well.
While most of the relevant information is generally available in this kind of digital record,
some important details might get missed out which can affect the overall diagnosis of the
patient. However, we can experience similar issues in paper-based documents as well. Often,
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DIGITAL HEALTH RECORDS
records are misfiled or sometimes lost by the nurses. I believe that a hybrid of the two both
digital and paper-based health record system is preferable for correct diagnosis.
As various hospitals and other professional settings are increasingly adopting the use of EHR,
I believe that it is of utmost urgency to learn and update our knowledge of eHealth and digital
record systems. It is because registered nurses like us have a significant role in providing
healthcare and managing the treatment plan and progress of the patients. I believe EHR to be
handy as it saves considerable time in documenting the patient-related notes which can be
utilized for other purposes such as patient monitoring. I find the EHR system particularly
beneficial as it enables communication with the pharmacy, makes clinical documentation
screens, calculators and educational documents regarding drugs and clinical data easily
accessible. Another fascinating feature of the EHR system is that it allows us to observe
trends in the clinical information over a specific duration of time and enables interoperability
among different medical devices which make the EHR system highly useful.
However, I find it difficult to understand some features and specific aspects of the
functionality of this digital health record system. Firstly, it is confusing to document patient
assessments and the care treatment provided as there are multiple places of storing similar
information. For instance, there is wounds skin integrity, and the questions asked include if
there are any abnormality and its location but again, the same documentation is asked during
wound dressing. Hence, it gets confusing as to the same question being asked twice. Clarity
on the same is required. Therefore, I believe that professional training and an ongoing
learning practice regarding the developments in eHealth is necessary for each nurse.
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DIGITAL HEALTH RECORDS
Evaluation
Nurses constitute the most extensive section of the healthcare sector utilizing the electronic
health record system. This reason makes the perceptions and attitudes of the nurses towards
the application of the digital record systems of prime importance. Various studies have been
conducted to record the perceptions and confidence of nurses in using electronic health
systems. One of the studies depicted a comprehensive quantitative correlation between the
characteristics of nurses and their acceptance of digital medical records. It displayed an
overall positive response from the nursing population in the use of EHR systems (Kim et al.,
2015). A study conducted by Abu Raddaha (2018) suggested that although about half of the
nurse population in the study were confident regarding their use of the digital medical record
system, appropriate training and guidance is required to use the system, particularly among
the nurses with less professional experience. Nurses with significant experience did not face
much trouble in using these electronic records.
Moreover, a quantitative study supported the design-related challenges faced in using
electronic record devices despite its advantage of reducing the time invested in documenting
paper-based records of the patient. It states the perceptions of various nurses and implies that
the EHRs available at present lack adequate design to aid the healthcare professionals in
utilizing these systems successfully (Strudwick et al., 2018). In conjunction, nurses viewed
EHR as a time-saving alternative to the traditional paper-based documentation. However, the
same study reveals that some sections of the nurses also found this system chaotic due to
excessive scrolling to find suitable data and unreliable due to incomplete details of the patient
which might be relevant for precise diagnosis. An attempt was made by the IT department to
resolve this issue by increasing the user-compatibility for its efficient use (Zadvinskis, Smith
& Yen, 2018). Another challenge noted in the application of the digital record systems was
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