Access to instant data speeds care

Imagine a time when following an accident, a micro-chip embedded in a person’s wrist could be scanned and the emergency personnel would immediately have an up-to-date medical record to help determine the appropriate treatment. Each of us would carry our medical record with us and could receive treatment no matter where we were without waiting for a hospital to transfer information. Or imagine a patient at home linked electronically to a hospital and all vital signs monitored and treatment prescribed accordingly. These kinds of medical practices will someday be possible, according to Connie Delaney, Ph.D., RN, FAAN, Director of the Office of Nursing & Health Informatics at the University of Iowa. “In the United States, since the early ’90s we’ve been on a very fast track to establish an electronic health record,” Delaney adds.

“Information is so much more accessible,” says Peg Bradke, R.N., M.A., and executive director of the heart center at St. Luke’s Hospital in Cedar Rapids. “This will improve patient care; it will improve critical thinking skills, because the nurse will be able to put lots of information together to quickly communicate with others.”

This increased use of technology impacts the quality of patient care especially during admission, while receiving direct nursing care and at discharge.

Admission

When you are admitted to the hospital, you are required to provide information about yourself, your health history and symptoms of health-related problems.

“In the past, one of the common complaints we got from patients is that we’re always asking the same questions over and over again,” says Pamela Manor, RN, clinical analyst at Mercy Hospital in Cedar Rapids. With new computer systems, if you’ve ever been admitted to the hospital before, the information from that visit is simply verified and updated.

“Even if the patient hasn’t been admitted to the hospital before, but has been to a Mercy Clinic, that information is available to the departments of the hospital,” adds Carol Watson, Ph.D., RN, and senior vice president of clinical services at Mercy Hospital.

Direct Care

While the patient is in the hospital, nurses gather information daily about such things as blood pressure, temperature, respiration, weight, and what is eaten.

“This information is entered into the patient’s record and a physician can access it without having to find a particular nurse or a particular piece of paper,” explains Bradke.

If the patient has lab work done, an X-ray, and is given medications, the doctor doesn’t have to wait for the separate pieces of paper to follow the patient; “Even if the paper chart is in radiology with the patient, the doctor can use the computer to see what meds the patient is taking and whatever else he needs to know. The doctor doesn’t have to wait for the chart,” Bradke says.

Discharge

When a patient is discharged from the hospital, instructions are given that list such things as procedures to be followed and medications to be taken.

“In the past, the paper copy of records was sent down to the records room. If a patient called with a question after being discharged, they would have to wait until the records were retrieved before the question could be answered. Now it can be dealt with as soon as the patient’s history is brought up on the computer,” says Bradke.

“Instructions are more legible, prescriptions are printed and easy for the pharmacist to read,” adds Manor.

Quality nursing is “about listening to the patient and being responsive,” according to Delaney. Informatics is a term applied to training nurses and other medical personnel “who know about computer science, who know about information science and then have a special set of skills and knowledge to help develop the applications that work.”

At Mercy Hospital, for example, there is a “point of care documentation task force composed of nurses, designing systems for nurses, so it works the best for them,” says Manor. These nurses meet with the software designers regularly to help coordinate the development of the hospital’s technology system. This helps ensure that the system will be designed to be usable by those who use it the most, the nurses, who will then be able to provide better patient care.

Computerized records are also used for home care visits. If a patient continues to need home care, “our home care department is fully automated,” explains Watson. “They have an electronic record. In the morning the home care nurse links in through the telephone and loads in patient information, goes to visit patients, and while visiting their patients enters information and can several times (during the visit) reconnect by telephone and send it back to the hospital.”

Cedar Rapids Gazette, Nursing Supplement, November 4, 2003

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