by Tina Dieckhaus RN-BC, NE-BC, CPHIMS, FHIMSSC
We have seen recent statements in the news that question the ability of our electronic medical records to share information. Most recently what may come to our minds is the Ebola patient in Dallas. Information was collected and entered in the electronic medical record that would be helpful for the care providers to know, but was not easily discernible amongst all of the other data.
This is not the place to get defensive about care, or system design. When we design our EMRs, we are providing tools to collect as much or more information about our patients than we ever were with our paper tools, but somehow, we are missing something. It seems that when we moved away from our non-structured, narrative documentation, we made it more difficult to tell the patient story; we made it more difficult to spotlight our focus on that unique fact that has just a bit more relevance than the data element would normally hold from our nursing judgment perspective.
I appreciate the focus this event in Dallas has had on forcing all of us to question the usability of our electronic medical records. In our facility we are now writing alerts that communicate if a patient has recently traveled to the African countries of concern, but this is reactionary and this approach will always require that someone be the first to miss some critical piece of information, allowing others to learn and react. We need to start considering system designs that will allow the clinical provider to discern what is pertinent and allow the EMR to easily spotlight and share that information proactively.