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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 2  |  Page : 124-129

Relationship between electronic medical record utilization and the quality of nursing care at Pediatric Oncology Hospital


1 Nursing Information (B.Sc. Nursing), Faculty of Nursing, National Cancer Institute, Cairo University, Cairo, Egypt
2 Professor of Nursing Administration, Faculty of Nursing, National Cancer Institute, Cairo University, Cairo, Egypt
3 Assistant Professor of Nursing Administration, Faculty of Nursing, National Cancer Institute, Cairo University, Cairo, Egypt
4 Professor of Pediatric Oncology, National Cancer Institute, Cairo University, Cairo, Egypt

Date of Submission18-Apr-2017
Date of Acceptance30-May-2017
Date of Web Publication12-Jan-2018

Correspondence Address:
Shimaa Ali Abd-Elmaksoud Romman
Clinical Instructor, El Araby Hospital, El Monfufya
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_20_17

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  Abstract 

Background Adopting of electronic medical record is to improve the quality of nursing care by new solutions to make the nursing have the scope of patient centered care.
Aim To assess the effect of using electronic medical record on the quality of nursing care. Descriptive correlational design was utilized to attain the aim of the present study.
Sample Convenient samples of 94 nurses.
Setting In pediatric oncology Hospital were recruited in the study.
Tools Data was collected through 3 tools developed by the researcher: First tool: demographic data sheet for staff nurses, second tool: electronic medical record nurses practice observational checklist to observe the nurse competencies on electronic medical record, Third tool: quality of nursing care observational chick list to observe nursing care provided to pediatric oncology patients.
Results The study shows that there is a highly statistical significances correlation between electronic medical recording and quality of nursing care dimensions.
Conclusion The present study concluded the utilization of electronic medical record by nurses was effective in providing high quality of nursing care. Recommendations preparing separated orientation program for the super-user, charge nurse and the supervision levels so that they can detect and follow the data entry defect of the nurses and guide them.

Keywords: Electronic Medical record “EMR”, Nursing Care Quality


How to cite this article:
Romman SA, Elmola MA, Elhamid MA, Zamzam MA. Relationship between electronic medical record utilization and the quality of nursing care at Pediatric Oncology Hospital. Egypt Nurs J 2017;14:124-9

How to cite this URL:
Romman SA, Elmola MA, Elhamid MA, Zamzam MA. Relationship between electronic medical record utilization and the quality of nursing care at Pediatric Oncology Hospital. Egypt Nurs J [serial online] 2017 [cited 2018 May 20];14:124-9. Available from: http://www.enj.eg.net/text.asp?2017/14/2/124/223097


  Introduction Top


Health care is an information intensive industry, in which quality and timely information is a critical resource. Information is the key to effective decision making and integral to quality nursing practice. Much of what nurses do involves information, which starts from assessing health care needs of patients, to developing nursing care plan, to implementing the actions, to evaluating the outcomes and to communicating patient’s information to other health care professionals. Beyond information management in day-to-day practice, in the 21st century, information is doubling every 5 years, if not tripling in quantity and quality. It is therefore crucial that nurses have access to the latest scientific information to support the delivery of high quality care and the development of nursing knowledge and theory. These have given rise to the emergence and increasing prominence in the field of nursing informatics (Olajubu, 2015).

Electronic medical record according to the latest definition from the National Alliance of Health Information Technology (NAHIT), “an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization” (2008, p. 6). An EMR characteristically contains lists of patient problems, medications, allergies, as well as health maintenance data, progress notes, various test results, and ordering functions (Steiner, 2009).

Nursing availability is correlated with positive patient outcomes in clinical settings. In order to improve the quality of patient care, hospital administrators are interested in increasing the amount of time nurses have available for direct patient care by reducing the amount of time nurses spend documenting in Electronic Medical Record (EMR) systems (Philipsen, 2014).

Electronic Medical Record (EMR) systems have the potential to improve quality of health care, streamline workflow and increase efficiency in the health care system. However, potential problems have also been identified, such as the cost of implementing and maintaining EMR systems, and the skills and training needed for using them (Mohan, 2013).

Work groups such as those in the Institute Of Medicine IOM have attempted to define quality of health care in terms of standards. Initially, the IOM defined quality as the “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” (Koy, 2015) This led to a definition of quality that appeared to be listings of quality indicators, which are expressions of the standards. These standards are not necessarily in terms of the possibilities or conceptual clusters for these indicators. Further, most clusters of quality indicators were and often continue to be comprised of the 5Ds – death, disease, disability, discomfort, and dissatisfaction 5 – rather than more positive components of quality (Mitchell, 2008).

In recent years, nursing care quality were generated and grouped into four domains: competence, caring, professionalism, and demeanor. A study reported that the six lived meanings of quality nursing care found: 1) Advocacy, 2) Caring, 3) Empathy, 4) Intentionality, 5) Respect, and 6) Responsibility. A group of researchers reported that the quality paradigm emphasizes doing things right and explored the nursing care quality by examining necessary ‘things’ left undone by nurses by using a cross-sectional survey method. In recent years, there has been global interest in the recruitment and retention of qualified nurses and the impact that nurse shortages may have on the nursing care quality delivered to patients. In particular, over the last two decades nursing has seen its numbers decrease through a combination of fewer people entering the profession, a crisis in retention as a result of many qualified nurses leaving because of stress, nursing staffing level, nurse practice environment, burnout and job dissatisfaction, and an ageing nursing workforce (Koy, 2015). High-quality nursing care is explicitly defined in these standards as being consistent with current professional knowledge and increasing the likelihood of desired patient outcomes (Burhans, 2008)


  Significance of study Top


The study assess the effect of using electronic medical record on nursing care which will be helpful in providing an evaluation for the quality of nursing care. Electronic medical records improve quality of care by providing information that paper cannot, by making information available where needed, increases coordination of care by bringing all patient information together, support follow-up information for patients, improve patient and provider convenience and ensure adequate privacy and security protection for personal health information. Nurses have always faced the challenge of reconciling documentation with quality patient care. But the electronic medical record increases time at the bedside, improves physical environment, increases communication and collaboration of care delivery team and real short time access to medical record which all help in saving the nurses time. So the study will reveal the impact of electronic medical record on how the nurses utilizes the time and achieving the best quality of care. Results of the study would then enable nursing system staff to design future Modifications to the EMR system and meet essential requirements for quality of nursing care and time utilization for nurses.


  Subject and methods Top


The aim of the study was to assesses the effect of using electronic medical record on the quality of nursing care in pediatric oncology hospital.

Research question

What is the effect of using electronic medical record on the quality of nursing care?


  Material and methods Top


Research design

Descriptive, correlational design approach was utilized in the current study.

Sample

A Convenient sample (no.94) of all nurses working on Electronic Medical Record at inpatient floors of pediatric oncology hospital. Were selected according to the following predetermined inclusion criteria; All nurses at in-patient floors use Electronic medical record system, have minimum (6) months experiences in selected setting." nurses with different educational levels.

Setting

The study was conducted at pediatric oncology hospital. The hospital has 200 bed capacity divided into outpatient services and inpatient facility. The hospital inpatient have(5) floors each one contain (30)rooms that are (10)semi private which have two beds for two patients and their care givers, the rest (20) rooms which is fully private contain one bed for one patient and his care giver. The study data collected from the 3rd and 5th floors.

Tools of data collection

Three checklists were developed by the researcher based on the related literature.

1st electronic medical record observational chick list, to observe the nurse competencies on the used system, it contains 9 dimensions contains (93) items
  1. 1st Dimension: Frequency distribution of Ergonomics “uses computer technology safely”, it contains 9 elements for evaluation.
  2. 2nd Dimension: Frequency distribution of demonstrates keyboarding skills the nurse use it contains 7 elements for evaluation.
  3. 3rd Dimension: Frequency distribution of navigates in windows effectively contains 4 elements for evaluation.
  4. 4th Dimension: Frequency distribution of uses computer skills in endorsement process contains 5 elements of evaluation.
  5. 5th Dimension: Frequency distribution of client information review “CIR” from the power chart application contains 8 elements of evaluation.
  6. 6th Dimension: Frequency distribution of check data of result review for time period contains 5 elements of evaluation.
  7. 7th Dimension: Frequency distribution of retrieves information of form browser contains 5 elements of evaluation.
  8. 8th Dimension: Frequency distribution of inquiry information of notes contains 16 elements of evaluation.
  9. 9th Dimension: Frequency distribution of uses system applications to enter client data contains 16 elements of evaluations.
  10. 10th Dimension: Frequency distribution of uses information management systems for client education contains 9 elements of evaluation.
  11. 11th Dimension: Frequency distribution of system support skills contains 4 elements of evaluation.
  12. 12th Dimension: Frequency distribution of information system security, confidentiality and privacy contains 5 elements of evaluation.


As for scoring system, Weighted scores were assigned to the response, as the following: if the response was done (1) score were assigned, which means that the nurse done this items. Not done was taken (0) score, which means that the nurse not done this items. Not applicable was taken (0) score, which means that the used electronic medical record doesn’t support this items with the appropriate application and those items removed after the pilot study.

2nd quality of nursing care Observational chick list to observe pediatric oncology patients contains 5 dimensions contain (54) elements
  1. 1st Dimension: Frequency distribution of Competency with pediatric oncology care technical& procedural skills it contains 2 elements of evaluation.
  2. 2nd Dimension: Frequency distribution of makes a physical assessment of the pediatric oncology patients’ health status it contains 16 elements of evaluation.
  3. 3rd Dimension: Frequency distribution of Initiates nursing actions within the protocols and policies developed for the unit it contains 20 elements of evaluation.
  4. 4th Dimension: Frequency distribution of Competency with decision making it contains 6 elements of evaluation.
  5. 5th Dimension of frequency distribution of Competency with teaching/interpersonal relationship& communication it contains 10 elements of evaluation.


As for scoring system, the responses to the items of quality of nursing care observational checklist were (yes, no, not applicable, not observable). Weighted scores were assigned to the response, as the following: if the response was yes (1) score were assigned, which means that the nurse done this items. No was taken (0) score, which means that the nurse not done this items. Not applicable was taken (0) score, which means that there was no appropriate equipment or policy to support application those items which removed after performing the pilot study.

Pilot study

The pilot study was carried out on (17) nurses which constitute 10% of the study sample to examine the applicability and clarity of the items, and to estimate the time needed to complete the two Observational checklists for nurses. Based on the pilot study analysis minor modifications were made in both two observational checklists.

Validity and Reliability

Tools content validity was established by 5 experts in the field of nursing informatics and expert staff in the corresponding hospital to test the content validity. Each of the experts was asked to examine the instrument for content coverage, clarity, wording, length, format, and overall appearance. The instruments were tested and demonstrate good internal reliability measured by using Alpha chronobach s’ coefficient it equal (0.85).

Procedures

Upon receiving the official approval from directors of the selected hospital and the acceptance of the participation from the staff nurses to conduct the study the investigator received a list includes names and categories of all staff nurses enrolled in the three 2 medical in-patient floors, the investigator explained to nurses the aim of the study & invited them to participate in the study. After oral explanation, the investigator gave the participants the sociodemographic sheet in their working places to be filled. The time spent to fill the sociodemographic sheet was ranging between 5 to 10 minutes. The investigator observes the participants all over the day from receiving the patient up to endorsing their patients and reviewing the electronic medical record in their working places. Data was collected for nine months from February 2012 till November 2012.

Statistical design

The data collected from the participants were coded and entered into the Statistical Package for the Social Sciences (SPSS), version 20 for analysis. The negative items scores were reversed during the statistical analysis. Data were presented using descriptive statistics in the form of frequency distribution; percentage, mean, and stander deviation .Persons’ correlation coefficient was also used to test relation between nurse’s user competencies, quality of nursing care.

Legal and Ethical considerations

Once the official permission from ethical committee is granted to proceed with the proposed study, Participation in this study is voluntary; each subject has the right to withdraw from the study without any rational. Informed consent has been obtained from the nurses. Confidentiality and anonymity of the subjects are assured through coding of all data. All subjects had been observed through their routine work. Nurses had been assured that these data will not be reused in another research without their permission.


  Result Top


[Table 1] shows that the highest mean was navigates in windows effectively (2.78, ±0.35), followed by uses computer skills in endorsement process (2.70, ±0.34), followed by information system security, confidentiality and privacy (2.61, ±0.41), followed by demonstrates keyboarding skills the nurse use (2.44, ±0.42), followed by client information review from the power chart application (2.20, ±0.17), followed by system support skills (1.77, ±0.39), followed by uses information management systems for client education (1.59, ±0.20), followed by uses system applications to enter client data (1.34, ±0.19), and the lowest mean was ergonomics “uses computer technology safely”. (0.90, ±0.35).
Table 1 Mean and SD of dimensions of observed electronic medical record nurses practice. No=282

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[Table 2] shows that the highest value makes a physical assessment of the pediatric oncology patients’ health status (3.00, ±0.26), followed by Competency with pediatric oncology care technical& procedural skills (2.88 ,  ±0.26), followed by Competency with decision making (2.09, ±0.37), followed by Competency with teaching/interpersonal relationship& communication (1.83, ±0.40), and the lowest value Initiates nursing actions within the protocols and policies developed for the unit (1.53, ±0.27)
Table 2 Mean and SD of dimensions of quality assessment of nursing care

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[Table 3] shows that there is highly significances correlation between dimensions of electronic medical recording and dimensions of quality of nursing care.
Table 3 Pearson correlation between dimensions of electronic medical recording and dimensions of quality of nursing care

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  Discussion Top


With respect to the observed electronic medical record (EMR) nurse’s practice, the study finding showed that, the highest mean nurse’s practice scores was related to navigate in windows effectively, followed by client information review from the power chart application, and ergonomics “uses computer technology safely respectively. This may be due to which system integration, adequate technology infrastructure which properly allocated all over the hospital, availability of informatics nurses who conduct electronic documentation course that the support the implementation of the EMR and in-service training personally who support nursing staff all over the day, automation of whole nursing workflow processes, including clinical documentation and electronic recording of medication administration. Implementation of Clinical Decision Support (CDS) and Computerized Physician Order Entry (CPOE) all of this helped in make the nurses who adhere to the system all over their work process. This result was in agreement with Miller (2017) reported that nurses were highly skilled in informatics computer competencies.

Concerning to dimensions of Quality assessment of nursing care, the study finding revealed that the highest mean nursing care practice score was related to perform a physical assessment of the pediatric oncology patients’ health status, followed by Competency with pediatric oncology care technical& procedural skills, followed by Competency with decision making, followed by Competency with teaching/interpersonal relationship & communication, and the lowest mean was Initiates nursing actions within the protocols and policies developed for the unit. This is may be due to the hospital were preparing for joint commission of accreditation, the proper general orientation, proper hiring of experienced staff, continuous and closed supervision and direction of nursing management and training departments. Inconsistent with Freitas (2014), reported that “the quality of nursing care were investigated. The findings revealed that none of the nursing care reached the desirable level and that only two were considered safe − hygiene and physical comfort and nutrition and hydration.

Regarding to Pearson correlation between dimensions of Electronic Medical Record and dimensions of Quality of nursing care, the study revealed that there is a highly statistical significances correlation between total dimensions of Electronic Medical Records and total dimensions of Quality of nursing care. This may be due to electronic medical record can be used to the nurse’s advantage to know comprehensive patient data and information, collecting and processing information about the patient, electronic medical record save the nurses time spent in indirect care and save more time for the direct care to the patient, uses the closed loop electronic medication administration prevent the late and early medication administration and applicate the medication administration rights to decrease errors, electronic medical record also cumulative and chronological reports for patient condition progress. This study was consistent with Kutney-Lee, (2011) study which reported that “the implementation of a basic electronic medical record, demonstrate promise in bringing about improved and more efficient nursing care, better care coordination, and safety for patients, also associated with reductions in medication administration errors and time spent on documentation, as well as improved quality of nursing documentation. Nurse communication and workflow processes, such as documentation, medication, and patient discharges and transfers. The study finding was inconsistent with Furukawa, (2010) he reported that “advanced electronic medical record applications may increase hospital costs and nurse staffing levels, as well as increase complications and decrease mortality for some conditions. Contrary to expectation, we found no support for the proposition that EMR reduced length of stay or decreased the demand for nurses”


  Conclusion Top


The study was undertaken to assess the effect of using electronic medical record on the nursing care and nurses time utilization in Children pediatric oncology Hospital. The present study concluded that levels of practice of observed electronic medical record for nurses are high competencies of practice. According to levels of practice of Quality assessment of nursing care the result concluded that the majority of the sample between moderate quality of care and high quality of care. Also the study reflected that there is highly significances correlation between dimensions of Electronic Medical Recording and dimensions of Quality of nursing care.

Recommendations

Based on the findings of the present of the study, the following recommendations were deduced:
  1. Preparing separated orientation program for the super-user, charge nurse and the supervision levels so that they can detect and follow the data entry defect of the nurses and guide them.
  2. Activating alert system of voice and application email between the users.
  3. Connect the EMR used to the vital signs monitor to enter the data automatically to the patient file.
  4. Complete the closed circle of electronic medication administration record.
  5. Conducting more studies on the other EMR nurses’ competencies levels will be helpful in determining the best practice of adopting EMR.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

1.
Burhans L (2008). what is good nursing care? The lived meaning of quality nursing care for practicing nurses. http://thescholarship.ecu.edu/bitstream/handle/10342/1085/umi-ecu-1018.pdf  Back to cited text no. 1
    
2.
Freitas J (2014). Quality of nursing care and satisfaction of patients attended at a teaching hospital. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692014000300454  Back to cited text no. 2
    
3.
Furukawa M (2010). Electronic Medical Records, Nurse Staffing and Nurse-Sensitive Patient Outcomes: Evidence from California Hospitals. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910563/  Back to cited text no. 3
    
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Koy V (2015). Nursing care quality: a concept analysis, Article in International journal of medical sciences Cambodian Council of Nurses. https://archive.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/nurseshdbk.pdf  Back to cited text no. 4
    
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Miller R (2017). Physicians’ Use of Electronic Medical Records: Barriers and Solutions. http://content.healthaffairs.org/content/23/2/116.full  Back to cited text no. 5
    
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Mohan M (2013). Effect of an electronic medical record information system on emergency department performance. https://www.mja.com.au/journal/2013/198/4/effect-electronic-medical-record-information-system-emergency-department  Back to cited text no. 6
    
7.
Mitchell P, Hughes R (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 1 Defining Patient Safety and Quality Care.  Back to cited text no. 7
    
8.
Olajubu A (2015). Competencies and Barriers to the use of Nursing Informatics among Nurses in Primary, Sec-ondary and Tertiary Healthcare Facilities in Nigeria. http://docplayer.net/15978075-Competencies-and-barriers-to-the-use-of-nursing-informatics-among-nurses-in-primary-sec-ondary-and-tertiary-healthcare-facilities-in-nigeria.html  Back to cited text no. 8
    
9.
Philipsen N (2014). A Mixed-Methods Assessment of the time spent Documenting by nurses using an electronic medical records system. http://bart.sys.virginia.edu/sieds14/papers/1569910083.pdf  Back to cited text no. 9
    
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Steiner B (2009). Electronic Medical Record Implementation in nursing practice: A literature review of the factors of success. http://scholarworks.montana.edu/xmlui/bitstream/handle/1/2347/Steiner B0509. pdf?sequence=1  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
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