Electronic Documentation and Patient Safety - Essay on Public Health

The introduction of technology in the health sector has helped improve the status of the healthcare system. However, the debate that has emerged in the recent years over the role of electronic documentation in the healthcare facilities seem to suggest that introducing electronic documentation is a bad idea in the first place. Even though the discussion is ongoing in various fields of study, what remains clear is that electronic documentation is critical especially when it involves patient safety. This paper argues that the role of electronic documentation in the healthcare system is to enhance and improve the patient safety.

Technology has been praised for the advancement of the healthcare systems. There are those who believe that electronic documentation has contributed to the healthcare positively. Also, there are those who believe that the safety hazards associated with the use of electronic documentation are significant and should not be ignored. The electronic documentation includes electronic medical files, prescriptions, and guidelines for medical support (Raposo, 2015). According to the author, the modality of the medical record that electronic documentation has brought has significantly transformed the healthcare system. It also allows new possibilities; for instance, one can analyze and compare medical results with other data within the same organization. Consequently, the implementation of the electronic documentation caused rapid and massive transformation in the healthcare service delivery in the recent years. Therefore, it would be inappropriate and undermine to claim that electronic documentation is just a mere replacement of sheets and more paperwork; it is beyond that.

On the other hand, the same technology has been blamed for the failures and shortcomings in the healthcare sectors. According to Bowman (2012), the adoption of electronic health record system can enhance the expectations of many people who rely on the services because of its cost-effectiveness and better quality care services. However, the increased rate of unintended impacts has raised concerns from various stakeholders. Improper use of the electronic health record systems can jeopardize the whole healthcare system. As a result, this can affect the integrity of the information coming from the electronic sources; thus, resulting in errors that can endanger the lives of patients. According to CNO (2017), the patient safety is the first priority for the Canadian registered nurses. A registered nurse is expected to provide the healthcare services to the best of his/her knowledge. Therefore, they charged with the responsibility of keeping the patients safe from physical, psychological, and emotional harm.

According to Bowman (2012), despite the promising role of electronic documentation especially enhancing the quality care and patient safety, its use has been associated with potential safety hazards. Accountability is not guaranteed in its use and this makes not on ineffective but also inefficient. Raposo (2015) also conquers with Brown regarding the potential risks associated with the electronic documentation system in the healthcare sector. According to the author, even though the current state of the electronic document is reliable, but it is still not without the dangers such as cyber-attacks and computer bug. Such problems can leave the system inoperative; thus, critical information regarding the patients medications, diagnosis, and personal details can be lost. However, the impact of lost information can be enormous especially when it comes to patients safety. Computer virus or cyber-attacks can lead to misplaced files which can result in misdiagnosis of the patient. Further, the systems failure can also lead to untimely treatments for patients. There cases that have been reported where a patients treatment is delayed due to the wrong information obtained from the electronic documentation system. As Raposo (2015) explains, the treatment of a cancer patient was delayed for years because instead of the system refer the physician to the immediate previous examination it referred him to the older examination which did not present the abnormalities. Such problems may be risky to the patients safety. Healthcare providers are not only charged with the responsibility regarding the patients safety because they are paid but because they are guided with the code of ethics which requires them to provide not only competent and ethical care but also safe care (CNO, 2017). Due to the much workload associated with the healthcare service delivery, many countries have integrated the electronic documentation system to help reduce the workload and improve service delivery.

Electronic documentation in Canada and many other countries that have adopted the system do not have a proper regulatory framework to monitor the systems safety and effectiveness. In Canada, there is a general framework, The Medical Devices Program which is managed and regulated by the Standards Council of Canada (CNO, 2017). Despite the fact that this body increasingly makes policies that cover software used in the healthcare system, it has not been able to monitor and control the operations of some of the following; computerized provider data entry, information technology, electronic health records, and electronic health medication and administration.

Meeks, Takian, Sittig, Singh, and Barber (2013) note that despite the advantages of an electronic documentation system in the healthcare system, one cannot refute the challenges associated with the system especially when it comes to patient confidentiality. According to the authors, protecting the patient confidentiality is a major issue in healthcare electronic documentation (Meeks et al., 2013). The author notes that if precautions are not taken, patients personal information can remain open for others to access. Every patient is entitled to the protection of information irrespective of gender, race, social class, or even age. In Canada, there are various legislations dealing with the patient safety and protection issues including the personal health information and confidentiality. According to the CNO (2017), Personal Health Information Protection Act (PHIPA) of 2004, Quality of Care Information Protection (QOCIPA) of 2016 are among the key policy frameworks which protect the interest of patients while they seek medical care in various health facilities. According to the CNO (2017), even though the personal information regarding patients is collected by the hospital it is still their property and when such information is needed their consent should be considered. The above legislation recognizes that the personal health information belongs to the patient and the hospital simply houses the information. Therefore, clients have the right to give the information, refuse to comply when asked about the information, or withdraw information that he/she has already given (CNO, 2017, p. 6). However, the decision to use or not use the information should not be anyone elses but the clients or patients. Raposo (2015) highlights the impacts of privacy breaches to patient safety citing that it is possible that critical information concerning the patient safety can find its way into the wrong hands.

The impact of technology in the healthcare sector is evident and one can easily note it. According to Meeks, Smith, Taylor, Sittig, Scott, and Singh (2014), investing in health information technology can improve both the safety and efficiency of patient care and also enhance knowledge discovery. However, this does not mean that it is all perfect especially when it comes to patients record safety. According to Meeks et al. (2014), there are emerging concerns over the negative impacts of electronic documentation in the healthcare institutions. Some of the negative impacts associated with electronic documentation include disruptions of clinical process and unsafe workaround to circumvent technology. Raposo (2015) examines the good impacts of electronic documentation in the healthcare system. The author explains that the electronic documentation enhances the information accessibility. One can easily access large data within a short period of time with the help of electronic documentation system. This, to some extent, can help patient safety as it can prevent medical errors. According to Raposo (2015), through the use of electronic documentation system, the medical teams can be able to access information that would have been unnoticed if one was using the manual system of documenting. Furthermore, the electronic documentation system can help in filtering information based on different criteria; for instance, by date, episodes, and also medication or drugs. This simplicity according to Raposo can help enhance the efficiency; thus, preventing situations that can lead to patients relapse. Raposo (2015) acknowledges the accuracy involved in electronic documentation regarding the dosage and drug prescriptions. According to Raposo (2015), with this accuracy in calculation, the medical team can easily note the consequence of interaction with other medications.

Raposo (2015) asserts that electronic documentation can enhance service quality in the healthcare institution. The CNO (2017) highlights the responsibilities of nurses and other healthcare stakeholders in protecting the patients. According to the CNO (2017), nurses and employers share the same responsibility of creating an environment that can support quality care practice. The CNO suggests some of the ways to realize and maintain quality practice setting, which includes care delivery processes, proper communication system, proper leadership processes, and professional development systems (CNO, 2017, p. 11). Integrating these strategies can help create a suitable and supportive environment for patients in the hospitals.

Despite the advantages and positive impacts associated with electronic documentation regarding patients safety, there are people who believe that it has not solved the problems in the healthcare systems. According to CMA (2014), the introduction of electronic documentation in the healthcare system is one of the recent technologies that have shown potential to enhance the patient safety. However, it can also contribute to adverse negative impacts that may affect the patients safety negatively. According to the CNO (2017), the most important responsibility of a nurse is to care for the patients. However, as explained in CMA report (2014), sometimes if the nurses rely too much on technology it can reduce the time required to observe the patients. According to the CNO (2017), nurses, who are the primary caregiver, are not involved in decision making regarding the development and implementation of the electronic documentation system. However, when it is brought in the hospitals, they are expected to use it. Lack of training on such new systems may increase the risks associated with patients safety. Bowman (2013) further notes that electronic documentation requires the care provider to have basic computer skills including the keyboarding skills. Again, the care provider needs to be able to enter the progress notes using a narrative format. However, a care provider who relies on the electronic document may reduce the collaboration with others whose contributions may enhance quality patient care.

The existence of the electronic documentation and paper format system is another challenge that can cause confusion and malfunctions that can patient safety relapse. According to Raposo (2015), most of the healthcare institutions have both paper format and computerized documentation systems that shows both the previous events and future events respectively. Integration of the two systems can w...