C802 Task 1 EHR Functions Analysis Example

Four EHR Functions on a Night Shift: Results, Documentation, Medication Management and Decision Support in a Composite Acute Care Hospital

Student Name

Leavitt School of Health, Western Governors University

C802: Foundations in Healthcare Information Management, Task 1

Course Instructor

Month Day, Year

Four EHR Functions on a Night Shift: Results, Documentation, Medication Management and Decision Support in a Composite Acute Care Hospital

Introduction

An electronic health record (EHR) is more than a digital chart. The Institute of Medicine described a set of core functions that an EHR system should perform to support safe, effective care, including health information and data, results management, order entry and management, decision support, electronic communication, patient support, administrative processes and population health reporting (Institute of Medicine, 2003). This paper explains four of those functions as clinical end users rely on them in a composite 240-bed acute care hospital: results management, point-of-care documentation, medication management through order entry and bar-code administration, and clinical decision support. For each it describes what the function does, how clinicians use it, what it improves and what risk it brings, and it closes with the role health information management (HIM) plays in keeping all four trustworthy.

Results Management

What it does. Results management delivers laboratory, imaging and pathology results into the patient's record as soon as they are finalized, displays them with reference ranges and trends, and routes abnormal or critical results to the responsible clinician. In paper systems, results arrived as printouts that could be filed in the wrong chart or never seen; the EHR puts every result in one place and can show a hemoglobin value beside the last ten values in a graph.

Clinical use. At 2 a.m. on a medical unit, a nurse sees a potassium result flagged as critical in the results inbox and on the patient's summary screen, calls the covering physician, and both view the trend of the past three days before deciding on replacement. The physician acknowledges the result electronically, which records that it was seen and by whom.

Benefit. Faster access to results shortens the time from test to treatment, avoids duplicate tests because prior results are visible, and gives clinicians trends rather than single values.

Risk. Electronic delivery does not guarantee action. A study in an outpatient setting found that some abnormal imaging results lacked timely follow-up even though an electronic alert had been sent to the ordering clinician, and that alerts which were never opened were the ones most likely to be missed (Singh et al., 2009). Inboxes crowded with normal results make critical ones easier to overlook. Hospitals therefore need rules for who owns a result when the ordering clinician goes off shift and for tracking results that return after discharge.

Point-of-Care Documentation

What it does. Point-of-care documentation lets clinicians record assessments, vital signs, interventions and notes at the bedside or close to it, using structured fields, flowsheets and templates alongside free text. Devices such as monitors can send vital signs directly into the record after a nurse validates them.

Clinical use. The night nurse on a surgical unit documents a postoperative assessment on a workstation outside the room: pain score, incision appearance and drain output go into flowsheet rows, and a brief narrative note records the patient's concern about nausea. The surgeon reviewing the chart on rounds sees the same entries a few hours later, time-stamped and signed.

Benefit. Documentation entered at the time of care is more accurate and complete than documentation reconstructed at the end of a shift. Structured fields also make data reusable: the same pain scores feed a quality report, and the same vital signs feed an early warning score.

Risk. Templates and copy-and-paste can fill the record with text that is not true on the day it appears. A review of the literature found that between 66% and 90% of clinicians routinely copy and paste, which can lead to note bloat, internal inconsistencies, errors carried forward and documentation placed in the wrong patient's chart (Tsou et al., 2017). A note that repeats yesterday's examination is not only misleading clinically; it also weakens the record as evidence.

Medication Management

What it does. Medication management covers the steps from ordering to administration: computerized provider order entry (CPOE) replaces handwritten orders, pharmacists verify orders electronically, and an electronic medication administration record (eMAR) with bar-code scanning confirms the right patient, drug, dose, route and time at the bedside.

Clinical use. A hospitalist orders an intravenous antibiotic at midnight through CPOE, which checks the order against the patient's allergies and kidney function. The pharmacist verifies it, and the nurse scans the patient's wristband and the medication bag before hanging it; the eMAR shows a warning if the bag does not match the order.

Benefit. The evidence for this function is strong. A pooled analysis estimated that processing a prescription through CPOE reduced the likelihood of error on that order by 48% (Radley et al., 2013). Bedside scanning adds a second layer. When one teaching hospital compared its units, those with bar-code eMAR made 41.4% fewer administration mistakes, setting aside errors of timing, and had about half the rate of potential adverse drug events (Poon et al., 2010).

Risk. Workarounds undo the safeguards. Nurses who scan a spare wristband taped to a workstation, or override warnings without reading them, bypass the checks entirely. CPOE can also introduce new errors, such as selecting the wrong item from a long drop-down list.

Clinical Decision Support

What it does. Clinical decision support (CDS) presents knowledge and patient-specific information at the moment a decision is made. It includes drug interaction and allergy alerts, order sets built on guidelines, reminders for overdue screening, and scores that combine data to identify patients at risk, such as a sepsis or deterioration score.

Clinical use. At 4 a.m., the deterioration score for a patient on the medical unit rises because of a climbing respiratory rate and falling blood pressure. The EHR places a banner on the chart and sends a message to the charge nurse, who assesses the patient and calls the rapid response team. The physician then opens a sepsis order set that bundles cultures, lactate and antibiotics.

Benefit. CDS brings evidence into routine decisions without requiring every clinician to remember every guideline, and it can catch patterns a busy clinician might miss.

Risk. The main risk is alert fatigue. When alerts fire too often, or for issues the clinician already knows about, users learn to override them, including the ones that matter. Decision support must be tuned: alerts reviewed regularly, low-value alerts removed and the remaining alerts shown to the right person at the right moment.

How the Functions Depend on Each Other and on HIM

The four functions are linked. Decision support depends on accurate results and documentation to calculate a score; medication management depends on correct allergy and weight documentation; and results management depends on orders being linked to the right patient and clinician. An error in one function flows into the others. That is where HIM's role lies. HIM professionals maintain the master patient index so that results and documentation land in the right record, monitor documentation integrity, including copy-and-paste practices and late entries, manage amendments and corrections, define what belongs in the legal health record and participate in governance committees that approve templates, order sets and alerts. They also use the data these functions generate to report quality measures and support research.

For the composite hospital, three practical steps follow from this analysis: a policy on copy-and-paste with periodic audits, a results ownership rule for handoffs and discharge, and a quarterly review of alert override rates with the pharmacy and nursing informatics teams. Each step protects the value of the EHR by protecting the quality of the information inside it.

References

Institute of Medicine. (2003). Key capabilities of an electronic health record system: Letter report. The National Academies Press. https://doi.org/10.17226/10781

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115

Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association, 20(3), 470-476. https://doi.org/10.1136/amiajnl-2012-001241

Singh, H., Thomas, E. J., Mani, S., Sittig, D., Arora, H., Espadas, D., Khan, M. M., & Petersen, L. A. (2009). Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: Are electronic medical records achieving their potential? Archives of Internal Medicine, 169(17), 1578-1586. https://doi.org/10.1001/archinternmed.2009.263

Tsou, A. Y., Lehmann, C. U., Michel, J., Solomon, R., Possanza, L., & Gandhi, T. (2017). Safe practices for copy and paste in the EHR: Systematic review, recommendations, and novel model for health IT collaboration. Applied Clinical Informatics, 8(1), 12-34. https://doi.org/10.4338/ACI-2016-09-R-0150