The importance of digital care: From EHRs to evidence-based care-planning
October 7, 2022
By Maria Kulibaba, Tim Sisson
As digital healthcare and EHRs become a requirement in the UK and beyond, nurses are increasingly being called on to document their care electronically
In the image above: Elsevier Health’s inaugural Clinical Decision Support Dialogue event brought together thought leaders, customers and industry experts.
The NHS(opens in new tab/window) is undergoing digital transformation, and technology is continually opening up new possibilities for prevention, care, and treatment. The UK government has stated that by December 2023, 90% of NHS Trusts need to have Electronic Health Records (EHRs) in place, and the other 10% need to be implementing them.
What does this mean for nurses?
Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, the treatment provided, and pertinent patient information to support the multidisciplinary team to deliver great care.
To explore this topic and the challenges it presents, Elsevier Health held the inaugural Clinical Decision Support (CDS) Dialogue event earlier this year in London, bringing together thought leaders, customers and industry experts. Elsevier’s Tim Morris(opens in new tab/window), VP of Go-To-Market EMEALAAP (Europe, the Middle East, Africa, Latin America and Asia Pacific), facilitated a roundtable discussion with:
Helen Balsdon(opens in new tab/window), RN, Digital scholar and Head of Digital Nursing Practice & Research; Deputy Chief Nursing Informatics Officer (CNIO) at NHS England.
Dawn Dowding(opens in new tab/window), PhD, Professor in Clinical Decision Making, School of Health Sciences at the University of Manchester.
Annette Gilmore(opens in new tab/window), PhD, Nurse Advisor and Standards Developer for the Professional Record Standards Body (PRSB) and eHealth Forum Chair at the Royal College of Nursing (RCN)
Speakers touched upon how accurate care documentation supports increased quality of care, the avoidance of errors, improved efficiency, cost benefit, and provider and patient satisfactio
Opportunity to improve the quality of care
The COVID-19 pandemic has changed the way we think about healthcare while sparking major advances in nursing care globally. The nursing profession is increasingly harnessing emerging technologies, whether by facilitating the delivery of virtual care in the community or via the introduction of EHRs in hospitals.
Accurate documentation is essential to maintain continuity of care and inform health professionals of ongoing treatment plans. “Documentation helps us evidence the care we have given and articulate the nursing contribution to care,” Helen Balsdon said during the discussion.
EHRs offer many advantages for nurses, including providing medication reminders, preventing drug interactions, and facilitating immediate access to a patient’s medical history and documentation of clinical care. Prof Dawn Dowding summarized these points following the session, saying:
Good care documentation is important for communication of care across health and social care boundaries, both for patient safety reasons and to enable the evaluation of the impact of nursing care on patient outcomes.
Providing real-time information about the care being provided to a patient helps healthcare providers respond quickly and accurately to improve outcomes.
Training as a barrier to digital solutions
As healthcare organizations move from paper-based to digital documentation, clinicians should feel confident accessing up-to-date and quality-assured digital health solutions. Digital health is becoming a high priority in government, NHS organizations and Royal Colleges; however, there is a gap between what is expected and the education received by staff and medical students to enable its implementation.
It has additionally been reported that there is inconsistent training provided on the importance of care documentation, particularly among junior doctors. This can lead to poor follow‐up and documentation practices, as well as a variability of practice.
Looking ahead, digital health education must be prioritized and universally included within training, continuing professional development activities, and medical school curricula. At the CDS Dialogue, attendee Pamela Stephenson(opens in new tab/window), Nurse Information Officer at University College London Hospitals NHS Foundation, outlined the importance of education in successful care documentation:
Education needs to be a huge cornerstone of any conversation. If we miss education out of the conversation, then we miss out the fundamentals of where we go with the documentation.
Cultural considerations are critical to the future of care documentation
Uncertainty remains regarding the next steps the nursing profession should take to increase and optimize its use of digital technology. This challenge is exacerbated by the global diversity of the profession, including unequal access to resources such as technological infrastructure maturity and expertise.
Huge differences exist among countries and regions across the world in terms of the digitalization of healthcare processes, access to internet connectivity, and transparency of health information processes. Looking ahead, it is vital that we incorporate cultural information in care documentation to ensure care provision is always based on an assessment of individual needs, guaranteeing the provision of patient-centric, culturally sensitive healthcare.
Bringing clinical, research and education leaders together at events such as Elsevier’s CDS Dialogue provides an opportunity to share experiences and data. This, in turn, helps provide a sound evidence base for the potential benefits of good care documentation across health systems for nurses, midwives and allied health professionals to align with evidence-based care, patient safety and quality guidelines.
Watch a video(opens in new tab/window) about the event.