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Expert Perspective: Sharable, comparable nurse data lacking in electronic health records

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Sharable, comparable nurse data is lacking in the nation’s electronic health records, according to Bonnie Westra, Ph.D., R.N., associate professor and director of the Center for Nursing Informatics at the University of Minnesota.

But it’s not for lack of nurses entering patient health information into the record. There’s arguably, in fact, too much patient data being entered.

“What we’re faced with is a challenge of how do we better streamline data, standardize terms used, and standardize documentation to better reuse the data coming in?” said Westra.

In other words, usability of the data has room to grow.

With nurses making up the single largest group of health care hospital workers in the United States, making full use of the patient data being entered is a big opportunity. Complete records on pressure ulcers and patient safety errors, for example, could lend health researchers and health systems a better understanding of patient needs and care improvement opportunities.

Effective electronic record keeping is still relatively new to much of the health care field. And while the electronic health record’s primary purpose is to track an individual patient’s health, the record has a secondary use—setting it apart from paper records—as well. Big data can help identify trends in population health and improve hospital workflow in a way paper charts could not, creating opportunities that are much more impactful.

Bonnie Westra, Ph.D., R.N.

“A lot of unnecessary money is spent,” said Westra, referring to the sizable sum health care agencies sink into manual chart reviews. Instead of pulling data out of systems in a cost-efficient way, manual reviewers must go through records one-by-one in search of the information they seek. That system is “getting better” according to Westra, but in some cases still can involve faxes and paper, and different or incomparable nursing language used across systems.

The need for improved implementation and optimization is widely acknowledged. National Public Radio’s Shots Blog recently elaborated on the physician-reported frequent inefficiency of electronic health records.

According to Westra, who has also sat on the Minnesota e-Health Initiative Advisory Committee since 2007, there are common nursing languages that already exist, enabling the opportunity for making some progress toward universal adoption. If widely implemented, it could make pulling data out of big systems much more streamlined.

Last year, Minnesota Commissioner of Health Edward Ehlinger approved a recommendation to implement a standardized nursing language across EHRs statewide. The U of M Center for Nursing Informatics is leading a national collaboration to streamline nursing documentation across the U.S. as well.

Added to that, informatics competencies are now built into nursing school curriculums nationwide – U of M School of Nursing curriculum included. That new standard just might provide an advantage to the next generation of health care providers, looking to make nurse data more easily exchanged … to the health benefit of all.

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