Written patient care records have been around ever since the days of Florence Nightingale, however it was not until the 1920’s and the creation of the Lloyd-George folder that formal medical care records were kept (Thompson and Wright, 2003). In present times technology is increasingly being introduced within the National Health Service (NHS), its aims are clear; to improve the standards of care for patients and to provide an enhanced working environment for its employees (Cooper, 2012).
In 2002, the Department of Health (DoH) launched its National Programme for Information Technology (NPfIT) within the NHS, at a cost of ? 11. 4 billion. The aim of the programme was to provide electronic medical records for every patient in the UK by 2010 this would then change the way in which the NHS and health care professionals use information, therefore providing better services and ultimately improving patient care (National Audit Office, 2011).
The topic of this assignment is to discuss the electronic care records system. This has been chosen as nurses have a professional and legal duty to keep accurate records (Wood, 2003), they record vital information about their patients throughout their shift, which they then have to communicate to other members of the multi–disciplinary team. Accurate documentation plays a significant part in the care of a patient; it improves accountability and provides written evidence of the care that a patient receives.
The Nursing and Midwifery Council (2009) state that good record keeping is a key element of nursing and plays a vital role which aims to promote safe and effective care for every patient, as patient records provide evidence of the decisions made and of the care delivered. Previously patient’s medical records have been held by their GP’s but with the development of electronic patient records these can be shared to allow NHS staff access to important medical information (Anon, 2010). Electronic care records
The documentation of a patient’s care is of vital importance to their health outcomes as it used to document changes in a patient, this allows healthcare professionals to adjust care appropriately. The electronic care record aims to make documentation clearer and more accessible in doing this patient safety and care are improved as errors are less likely to occur (Robertson, Cresswell, Takian et al. 2010). The electronic care record can be described as being a digital account of a patient’s medical information; this can be viewed on a computer and shared effortlessly by healthcare professionals who are taking care of the patient.
Within this information the patients’ demographics can be found along with clinical notes, diagnosis, medications, allergies, past medical history, procedures and results of diagnostic tests (Robertson, Cresswell, Takian et al. 2010). Each and every patient will have their own electronic care records, which will be held on a central computer system (known as the spine). These care records will comprise of two parts: •Detailed care record – this will include patients medical history in full, which will be accessible to GP’s and hospital settings. Useful if a patient is referred into hospital (NAO, 2011).
•Summary care record – this contains vital medical information, such as allergies to certain drugs, which will be available to all NHS staff across the country that may provide treatment to the patient (NAO, 2011). NHS staff will have varying levels of access, which will be dependent on their role, for example administration staff will not be able to access any clinical information about a patient but will be able to access clerical information and any information which is deemed to be of a personal and sensitive nature will be put into virtual sealed envelopes that only specific staff will have access to (Parish, 2006).
As electronic health records will be held on files within a computer system it will enable healthcare staff to gain better access to patient information, which overall will benefit patient care by making it safer and quicker, therefore making it more personal to the patient (NHS, 2010). The information that is stored about patients health will be more accurate and up to date, therefore making it more reliable and promoting better relationships between the patient and the healthcare staff, even in emergencies, however patients do have the option to discuss with their G.
P’S what information they want to have stored within the electronic record about their health, which could lead to crucial information being omitted (NHS, 2010). NHS Connecting for Health (2012) suggest that this system aims to empower the patient by giving them a choice in how their own health care is managed, they will be able to access their own health records via HealthSpace, this enables them to choose when and where they would like to have treatment, for example, the choose and book system that is already in place, they will be able to order prescriptions online which GP’s will be able to send to the pharmacist electronically (Parish, 2006).
Unfortunately the NHS has not fared well with its endeavour to provide electronic care records for every patient to every hospital in the country, with completion expected in 2006; however, Franklin (2011) suggested that it would be unlikely that the programme would be ready until at least 2015; this could mean it is out-dated before being fully operational.
One of the challenges that the NPfIT encountered was to replace the existing health information systems that were already in use in various NHS settings, within a limited time frame, this has had a drastic affect, causing the implementation of electronic care records to be much slower to implement than was originally thought. It is now estimated that the programme is at least four years behind schedule (Shaw and Stahl, 2011).
Menachemi and Collum (2011) discuss the disadvantages of the electronic health record, for example the financial issues involved such as the initial installing of the equipment, staff training and ongoing maintenance costs, however most agree that as the electronic health record becomes more frequently available the cost will decrease and the benefits will outnumber the disadvantages. Other disadvantages include the use of unsecured networks which could lead to illegitimate access of patient files causing concerns over confidentiality (Laitinen, Kaunone and Astedt-Kurki 2010).
Carvalho, Reeves and Orford (2011) discuss the fact that all healthcare professionals should only look at patients’ records in the course of delivering care to their patients and that they only need to access the information that they are likely to need to do their job. Looking at patients’ notes out of interest contravenes all confidentiality guidelines and the NMC code of conduct (2010) which states that nurses must respect patient’s right to confidentiality.
Knott (2010) discusses that to protect the creation, storage and sharing of patient records various legislation, standards and guidance know as ‘Information Governance’ have been put into place such as the Computer Misuse Act 1990, Data Protection Act 1998 and Human Rights Act 1998. As the records will be shared between care providers these will need to be better protected, staff will be issued with a NHS smartcard which incorporates a chip and a pass code, staff will be responsible for logging out of patient records after they have accessed the information they require regarding patient care and must not let others use their card or details to access records.
Computers will be able to log staff details, for example who they are and if they have made any amendments to the records (NHS, 2010), however it has been suggested that duplication of information could occur about a patient as staff will write notes throughout their shift, transferring them onto the computer later on in the shift, this also causes an increase in the time taken to document patient notes (Laitinen, Kaunone and Astedt-Kurki 2010).
In 2011, The Department of Health issued a statement stating that the Government was going to discontinue the NPfIT as it was deemed to be not fit for its purpose of delivering modern IT to the NHS (DoH, 2011).
Although the NPfIT was discontinued, several elements were kept as these are well established within care settings, for instance the national network for the NHS (N3) which provides a broadband network which is used for communication (NHS, 2012), NHSmail which provides staff with secure email and directory service, used to transmit patient and clinical data and the PACS system which provides digital imaging as an aid to patient diagnosis (DoH, 2007).
Robertson, Cresswell, Takian et al. (2010) suggest that because many of the various NHS Trusts within the country have become autonomous (foundation trusts), they are now opting to implement their own system which they feel is more suited their organisations needs, as opposed to the standardised vision of NHS connecting for health.
Having a standardised system put in place will allow all healthcare professionals to access the same information and care plans, this will allow patients to receive a higher quality of care, however as more and more of the administration that was once written becomes computerised, such as the care plans used by nurses, there is an increased risk of failing to notice patients’ individual needs (Dahm and Wadensten, 2008). Robertson, Cresswell, Takian et al.
(2010) suggest that the standardised approach has now changed into various IT stems which are related to the NHS care records, for example patient administration and test ordering which have been implemented differently from trust to trust.
Conclusion Using electronic health records aims to facilitate the work of many healthcare professionals involved with the care of a patient, therefore improving the quality of care of the patient, however the multi-disciplinary team who use records to deliver healthcare to patients need to be proficient with using technology and be aware of data protection and data security which is put into place to protect the patient. It is the duty of all healthcare staff to ensure that the quality of data is paramount and that confidentiality is kept at all times.
There are many benefits regarding electronic patient records, they provide a much safer practice and continuity of care which itself can lead to patient satisfaction which in turn leads to patient empowerment in relation to how they manage their own care, however there have been many problems identified regarding the implementation of electronic records, such as costs, training and the frustration which has been caused by the delays in implementation.
Despite all of the problems that electronic health records have encountered support is still strong and they are still seen to be the way forward in promoting better healthcare for patients. The electronic patient record can be seen as being a vital element enabling a multi-disciplinary team to provide a modern health care service to its patients. References Anon. (2010) Q&A: Electronic medical records [online]. London: BBC Available at: http://news. bbc. co. uk/1/hi/health/8559817.
stm [Accessed 23/02/2012]. Carvalho, S. , Reeves, M. and Orford, J. (2011) Fundamental Aspects of Legal, Ethical and Professional Issues in Nursing. 2nd ed. London: MA Healthcare Limited. Dahm, M. F. and Wadensten, B. (2008) Nurses’ experiences of and opinions about using standardised care plans in electronic health records – a questionnaire study. Journal of Clinical Nursing [online] 17: pp. 2137-2145. Available at: http://dx. doi. org/10. 1111/j. 1365-2702. 2008. 02377. x [Accessed 2 March 2012].
Department of Health (DoH) (2011) Dismantling the NHS National Programme for IT [online]. Available at: http://mediacentre. dh. gov. uk/2011/09/22/dismantling-the-nhs-national-programme-for-it [Accessed 24 February 2012]. Department of Health (DoH) (2007) The Government response to the Health Committee report on the Electronic Patient Record. Cmnd 7264. [online]. Available at: http://www. dh. gov. uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080238 [Accessed 24 February 2012]. Cooper, A. (2012)