NURSING LEADERSHIP AND MANAGEMENT
Electronic Health Record - ANSWER Information relating to the past or future
physical/mental health, or condition of an individual that resides in electronic systems used
to capture, transmit, receive, store, or manipulate data for the primary purpose of providing
health-related services
Electronic Medical Record - ANSWER Information relating to the medical care received
by an individual; usually institution specific residing in electronic systems that are hospital or
health system based
Decision Support - ANSWER Provision of assistance via a computer application for the
purpose of assisting the nurse in decision making
Clinical Information Systems - ANSWER Used for the collection, integration, and
distribution of information to the appropriate department
Nursing Information System - ANSWER Part of a hospital system that standardizes
nursing records across the system
Computerized Provider Order Entry - ANSWER Automated systems for providers to
enter patient care orders and to access decision support databases
Advantages of EHR - ANSWER • Storing data in small space
• Accessible from remote sites to many people at the same time
• Information retrieval is almost instantaneous.
1
,• Provides clinical alerts, expert systems, and reminders
• Links clinicians to protocols, care plans, critical paths, literature databases, pharmaceutical
information, and other databases of health care knowledge
• Automated programs can create customized views to meet the needs of various
specialties.
• Improves risk management and provides outcomes assessment
• Improves clinicians' productivity
• Provides more accurate capture of financial charges and billing efficiency
• Increases patient satisfaction
Disadvantages of EHR - ANSWER • Startup costs for hardware, software, installation,
maintenance, increased technical personnel, training, and future upgrades are considerable.
• Learning curve for a new system of documentation is steep.
• Confidentiality, privacy, and security of the information are concerns.
• New hardware is nonportable or portable and breakable.
• Issues surrounding entry of data remain.
• Technical understanding is required to maintain the system.
2
,• Downtime is an issue.
Primary and Secondary Uses f Hospital Wide Info Systems - ANSWER Primary Uses
• Patient care delivery
• Patient care management
• Patient care support processes
• Financial and other administrative processes
Secondary Uses
• Education
• Regulation
• Research
• Public health and Homeland Security
• Policy support
Functionality of Information System - ANSWER • Improve patient safety—Each year in
the United States, tens of thousands of people die as a result of preventable adverse events
in health care (IOM, 2000).
3
, • Support the delivery of effective care—It has been suggested that only about 55% of
Americans receive recommended medical care that is consistent with evidence-based
practice guidelines (McGlynn et al., 2003).
• Facilitate the management of chronic illness—More than half of people with chronic
conditions have three or more health providers. Physicians and patients report difficulty in
the coordination of care with multiple providers (Leatherman and McCarthy, 2002;
Partnership for Solutions, 2002).
• Improve efficiency—Efficiency is the avoidance of waste. With the staffing and financial
challenges faced by many institutions, it is imperative that processes be improved.
• Feasibility of implementation—This takes into account the financial capability of an
institution to support such a system, as well as the personnel capacity for support
(Committee on Data Standards for Patient Safety, 2003).
The core functionalities for a computerized health information system are as follows:
• Health information and data—EHRs with defined datasets such as medical and nursing
diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test
results can ensure access to current patient data by those who need it.
• Results management—Managing all types of results (laboratory tests, radiograph results)
electronically has the distinct advantage of allowing access to the results in a more efficient
timeframe than with paper-based results. The automated display of results may also lead to
a decrease of redundant testing (Bates and Gawande, 2003).
• Order entry—Computerized provider order entry (CPOE) has been shown to decrease the
number of medi
4
Electronic Health Record - ANSWER Information relating to the past or future
physical/mental health, or condition of an individual that resides in electronic systems used
to capture, transmit, receive, store, or manipulate data for the primary purpose of providing
health-related services
Electronic Medical Record - ANSWER Information relating to the medical care received
by an individual; usually institution specific residing in electronic systems that are hospital or
health system based
Decision Support - ANSWER Provision of assistance via a computer application for the
purpose of assisting the nurse in decision making
Clinical Information Systems - ANSWER Used for the collection, integration, and
distribution of information to the appropriate department
Nursing Information System - ANSWER Part of a hospital system that standardizes
nursing records across the system
Computerized Provider Order Entry - ANSWER Automated systems for providers to
enter patient care orders and to access decision support databases
Advantages of EHR - ANSWER • Storing data in small space
• Accessible from remote sites to many people at the same time
• Information retrieval is almost instantaneous.
1
,• Provides clinical alerts, expert systems, and reminders
• Links clinicians to protocols, care plans, critical paths, literature databases, pharmaceutical
information, and other databases of health care knowledge
• Automated programs can create customized views to meet the needs of various
specialties.
• Improves risk management and provides outcomes assessment
• Improves clinicians' productivity
• Provides more accurate capture of financial charges and billing efficiency
• Increases patient satisfaction
Disadvantages of EHR - ANSWER • Startup costs for hardware, software, installation,
maintenance, increased technical personnel, training, and future upgrades are considerable.
• Learning curve for a new system of documentation is steep.
• Confidentiality, privacy, and security of the information are concerns.
• New hardware is nonportable or portable and breakable.
• Issues surrounding entry of data remain.
• Technical understanding is required to maintain the system.
2
,• Downtime is an issue.
Primary and Secondary Uses f Hospital Wide Info Systems - ANSWER Primary Uses
• Patient care delivery
• Patient care management
• Patient care support processes
• Financial and other administrative processes
Secondary Uses
• Education
• Regulation
• Research
• Public health and Homeland Security
• Policy support
Functionality of Information System - ANSWER • Improve patient safety—Each year in
the United States, tens of thousands of people die as a result of preventable adverse events
in health care (IOM, 2000).
3
, • Support the delivery of effective care—It has been suggested that only about 55% of
Americans receive recommended medical care that is consistent with evidence-based
practice guidelines (McGlynn et al., 2003).
• Facilitate the management of chronic illness—More than half of people with chronic
conditions have three or more health providers. Physicians and patients report difficulty in
the coordination of care with multiple providers (Leatherman and McCarthy, 2002;
Partnership for Solutions, 2002).
• Improve efficiency—Efficiency is the avoidance of waste. With the staffing and financial
challenges faced by many institutions, it is imperative that processes be improved.
• Feasibility of implementation—This takes into account the financial capability of an
institution to support such a system, as well as the personnel capacity for support
(Committee on Data Standards for Patient Safety, 2003).
The core functionalities for a computerized health information system are as follows:
• Health information and data—EHRs with defined datasets such as medical and nursing
diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test
results can ensure access to current patient data by those who need it.
• Results management—Managing all types of results (laboratory tests, radiograph results)
electronically has the distinct advantage of allowing access to the results in a more efficient
timeframe than with paper-based results. The automated display of results may also lead to
a decrease of redundant testing (Bates and Gawande, 2003).
• Order entry—Computerized provider order entry (CPOE) has been shown to decrease the
number of medi
4
