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What effect does the use of electronic nursing documentation record system have compared to the paper documentation in improving patient safety in hospital settings

Implementing Evidence-Based Practices

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Implementing Evidence-Based Practices

What effect does the use of electronic nursing documentation record systems have compared to paper documentation in improving patient safety in hospital settings?

Introduction

Nursing documentation is an integral part of nursing that has been in existence since time immemorial. Nursing documentation is a record of patients’ health information (PHI), including their presenting symptoms, alongside comments from health care providers detailing their discussion with the patients and their observations and judgments (Nwagbo, 2018). Nwagbo (2018) further traces the history of nursing documentation back to the ancient Egyptians when physicians used to carve patients’ medical history on walls in hierographic. Al-Aswad, et al. (2013) report that the first formal medical records were found among the Hippocrates around the 5th Century B.C. This short history shows how ancient nursing documentation is.

Since the current healthcare environment has massively incorporated new techniques of recording patient information and abandoned some old ones, it is evident that nursing document is subject to change and is highly affected by technological advancement (Albarrak et al., 2014). Currently, the are two common forms of nursing documentation – the traditional aper-based record and electronic-based record (O’Connor, 2020). Paper-record system entails entering patient information using physical means such as paper, discs, pens, and films, then storing them in physical storage facilities for future retrieval. Electronic-based records or Electronic Health Records (EHR) is a new and developing concept in which the patient information is recorded in a digital or electronic format using computers and other devices like phones and tablets (Kruse et al., 2016).

The growing technological advancement is commandingly spearheading a transition from paper-based documentation to EHR because of the innovations and inventions of such capabilities and their promise of better results (Paans and Müller‐Staub, 2015). Besides, there are inherent shortcomings of paper-based documentation that are hoped to be addressed by EHR. For instance, paper-based documentation is associated with large physical storage spaces, retrieval, and transfer challenges due to their physical nature, destruction, deterioration, obsolescence, and losses (Nwagbo, 2018A). It has been reported that EHR can address these problems to bring more stability, permanence, and safety of patient records, along with convenience and a faster way of recording, retrieving, and transferring patient records. For instance, Hyppönen et al. (2014) report that EHR supports clinical care processes, facilitate new technologies to increase care quality and patient safety, enables evidence-based management at the local, regional, and national levels by facilitating statistical information collection.

These benefits have resulted in the widespread adoption of EHR across the globe. According to Gatiti et al. (2021), the adoption of EHR has taken a steady increase for the past 15 years, with upper-middle and high-income countries like the UK and US taking a commanding lead. For instance, by 2012, 97% of primary care physicians in the UK reported using electronic medical records. However, such an aggressive and gradual implementation of EHR has not fully scrapped the use of paper-based documentation. This reluctance to fully abandon paper-based documentation is perpetuated by some of the benefits it has and the limitation of EHR that it can complement (Paans and Müller‐Staub, 2015). Akhu-Zaheya, Al-Maaitah, and Hani (2017) report that the overemphasised claims about EHR resulting in better health outcome, patient safety, and care quality has not been adequately confirmed. Therefore, it is logical to further compare and contrast both paper-based and electronic documentation to determine if EHR is the superior system of nursing documentation and can stand alone, or both systems are mutually dependent and should be used concurrently to complement each other.

The literature contains rich information based on evidence-based research and survey that will go a long way to prove the strengths and weaknesses of the two methods of nursing documentation. This is why this study was designed to be a systematic literature review that can effectively gather vital information from the literature for comparing and discriminating between paper-based records and electronic documentation (Kruse et al., 2016). From this review, one can generate essential details about the impacts and extent of the desired outcomes a given nursing documentation method might generate and the considerations and choices that the UK can make to enhance the effectiveness of the various strategies implemented to enhance patient safety in the country (Albarrak et al., 2014).

Research Questions

This study will answer the question:

1. What effect does the use of electronic nursing documentation record systems have compared to paper documentation in improving patient safety in hospital settings?
2. Between paper-based documentation and electronic medical record, which one is more effective in enhancing patient safety in hospital settings?
3. Should care providers strictly use EHR for nursing documentation or continue complementing it with paper-based systems for the sake of improving patient safety in hospital settings?

These questions follow the PICO guidelines that require a research question to contain the population (P), intervention (I), comparison/control (C), and outcome (O) (Hastings and Fisher, 2014). In PICO guidelines, the initials are represented as follows;

P – UK citizens, particularly healthcare providers

I – both paper-based and electronic documentation

C – comparisons between paper-based and electronic documentation

O – the differences between paper-based and electronic documentation

The relevance of these questions stems from the growing push for healthcare professionals to shift to electronic health records despite the persistent use of paper-based records. This brings the question of the reluctance to fully abandon paper-based records. Perhaps, there is still an indispensable benefit of paper-based documentation that can still not be relinquished in the health sector. Lavin, Harper, and Barr (2015) report the shortcomings of both paper-based and electronic calls for further studies to better identify and understand them to guide the generation of effective ways of overcoming the weaknesses and exploiting the strengths.

Therefore, instead of vouching for the adoption of one method in place of the other, researchers should do an objective comparison between the two methods to identify their evidence-based benefits and weaknesses before making informed and beneficial decisions. Few papers in the literature tend to compare these documentation systems side-by-side in terms of their effectiveness in improving patient health (Lavin, Harper, and Barr, 2015). This kind of systematic literature review concisely summarised the existing evidence to guide the comparison between paper-based and electronic documentation to guide policy and decision-making processes.

The Objective of the Study

This study aims to identify the various strengths and weaknesses of paper-based and electronic documentation recorded in the literature to compare them in terms of effectiveness in improving patient health and recommend the best way of going about the transition from paper-based to electronic documentation.

Methodology

This was a systemic review of the literature covering papers published between 2010 to 2022 on paper-based and electronic documentation. The review was conducted in March 2022. The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All the articles for this study were obtained on the Internet. Any database that could provide relevant papers for the study, including Cinahl, Psycharticles, Medline, Psychbooks, Web of Science, British Library, The Cochrane Library, Google Scholar, Science Direct, and Swetswise was considered. Search words used to generate the relevant papers included combinations of words such as paper-based, traditional nursing records, electronic documentation, electronic health record, EHR, improving health patient safety, United Kingdom, and the United Kingdom. Various papers with varying research designs were considered, including RCTs, non-RCTs, literature reviews, cohort studies, and so on. Both fully powered and pilot studies were considered.

Inclusion Criteria

The papers selected had to be evidence-based studies conducted in English-speaking countries, particularly the United Kingdom and the United States. They had to be papers published within the specified period (2010 – 2022) and capture the search words. Most of the databases could be set to autogenerate relevant papers from the UK, published between 2010 and 2022. Articles from databases that could not specify such exclusion criteria were identified manually through scheming or perusal.

Analysis and Synthesis

A narrative synthesis was conducted for all the included interventions. Studies were assessed by two reviewers for their methodological rigour, quality, and fitness for inclusion. Judgment of effectiveness was done via a consensus among the two reviewers and other professional authors and reviewers based on the efficacy of findings, reported information on discrimination and ratings given in the identified papers, the general agreement in the papers reviewed, along with other additional information and analysis. Propositions were drafted first, and redrafting was then done via an interactive process by a team of authors and reviewers before building a consensus.

Results

The initial search of the databases generated more than 10,000 papers. After applying the eligibility criterion in terms of date and place, the number was reduced to 67 articles. 27 more articles were removed because of some reasons, including geographical specificity and not being well suited in terms of content. Subsequent reviews excluded 12 more papers because they were not directly focused on the paper-based and electronic documentation understudy and patient safety. Search findings were displayed on a PRISMA chart obtained from UNC (2022).

 

 

						Studies included in review (n = 23) Reports of included studies (n = 2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig 1: Search findings displayed on a PRISMA chart obtained from UNC (2022)

 

 

 

Quality Appraisal

Three main themes, including positive impacts, negative impacts, and barriers were identified from the review, as shown in the table below.

Themes	Category	Sub-Category	Number of References
			Electronic record documentation	Paper-based documentation
Positive impacts
	Involving healthcare providers
		Better efficiency	5	3
		Better communication	7	5
		More organized at work	3	3
		Support disease and quality management	3	2
		Support learning and decision making	3	3
	Care for patient
		Improve the quality of care	7	2
		Better communication	9	3
		Patient empowerment	5	1
		Change in time spent for patients	5	2
Negative impacts
	Involving healthcare providers	Worse efficiency	7	2
		Increase workload	2
		Time-consuming	3	2
		Delaying information transfer and retrieval	4	2
	Care for patient
		Quality care	4	2
		Face-to-face or direct communication	1	5
Barriers
	Involving healthcare providers
		Lack of use involvement	3	1
		Poor training and technical support	5	2
		Computer knowledge and skills	6	2
	Data and information
		Security and privacy of data	6	3
		Data quality and accuracy	3	1

 

Table 1: shows the number of papers that evaluated the identified themes

Summary and Synthesis of the Papers

Electronic Health Record (EHR)

Among the positive impacts, most papers reported better efficiency, better communication, work organization, disease support and quality management, support for learning and decision making, improvement of quality of care, patient empowerment, and shortening time consumption (Fernando et al., 2012). Implementation of EHR improved efficiency by about a 7-11% increase in time consumption efficiency (Tsai et al., 2020). Scruth et al. (2014) associate this trend with lowering the time taken while taking notes and patient information and retrieving them. However, too much time spent on EHR and perceived difficulties in retrieving and locating data on the EHR were reported to hinder efficiency (Singh and Muthuswamy, 2013). Communication among care providers was highly improved from 72% to 93% with the aid of EHR functionalities, such as to-do lists, patient problem lists, and task assignments consumption (Tsai et al., 2020). However, concerns of direct communication among healthcare professionals being hindered were echoed because that can limit patient safety.

Most studies reported that EHR increases workload, and few reported perceived reductions in workload. There is a general agreement that EHR increases the organisation of work. However, associated factors such as poor cross-organisational connectivity, poor integration of current workflows, and communication ambiguity in the EHR can alter workflow. With the systematic storage of information in EHRs, 80% agree that it supports disease and quality management due to the ease of retrieval and transfer (Baumann, Baker, and Elshaug, 2018). EHR provides up-to-date knowledge that enhances decision-making. EHR was reported to improve quality by more than 23% by enhancing positive outcomes, patients’ preventive health behaviors, and guiding and reminding care provided on what to do (Campanella et al., 2016). However, associated cybersecurity issues such as unauthorized access and virus threaten these potentials.

Paper-based Records

Paper-based record system was also attributed with some advantages it has over EHR. For instance, Akhu-Zaheya, Al-Maaitah, and Hani (2017) found that paper-based records were better than electronic health records in terms of quantity and quality content. For women under maternity care, the paper-held records are their preferred documentation system because it brings more integration between the woman the health care provider (Hawley et al., 2014). Paper-based records are time-consuming compared to other EHR. It requires a large storage space that is hectic to maintain and retrieve information from (Tsai et al., 2020). Transferring information between health care providers is more cumbersome and time-consuming due to its physical nature.

Akhu-Zaheya, Al-Maaitah, and Hani (2017) report that when paper-based records and EHR were compared side by side in terms of structure and content attributes, the score for both paper-based records and HER ranges between 0–54 and 4–59 respectively. Though EHR shows better performance, paper-based records had more completed audited records than EHR. The use of paper is easier for most nurses and enables them to remember what they have written down (Hawley et al., 2014). Though electronic recodes can also enable such possibilities, most nurses are not used to how it works, and sometimes it requires more accessories like electronic/digital pen to note down something on a phone (Tsai et al., 2020). Such preferences and lack of knowledge have perpetuated the use of paper-based recorder.

Issues of Implementation

The PARiHS (Promoting Action on Research Implementation in Health Services) was applied to guide decision-making in accordance with the findings of the review. According to the PARiHS as described by Hunter et al. (2020),

SI = f (E, C, F)

where SI=successful implementation, E=evidence, C=context, F=facilitation and f=function of.

The evidence presented here alludes to both positive and negative impacts of paper-based records and EHR. Both paper-based records and EHR should be supported by the government to provide the resources needed and much effort made by individuals to take up positive aspects of these recording systems while avoiding or limiting their negative impacts (Neupane et al., 2014). Continuous evaluation is required to better understand how to exploit the positive impacts of paper-based records and HER and limit their negative aspects (Baumann, Baker, and Elshaug, 2018).

Discussion

The analysis summarised the strengths and weaknesses of both paper-based records and HER identified in the literature. A systematic review of the literature gives an objective evaluation of the nursing document, which is vital in determining the effectiveness of care delivery and patient safety (Baumann, Baker, and Elshaug, 2018). With effective documentation, there is an ease of communication and cooperation among health care providers (Coffey et al., 2015). According to the findings of this study, it is evident of a unanimous agreement the EHR should be adopted to enhance the effectiveness of care. Similarly, it is true that care providers still widely use paper-based documentation because of some benefits they find in it.

This study shows that EHR gives better quantity and structure of the record compared to paper-based records. EHR gives better completeness and legibility of documentation and, in turn, prevents missing information (McCarthy et al., 2019). Similar findings are also reported by Yu et al. (2013), (Nguyen et al. (2014), and Wang et al. (2013). However, EHR also has some limitations such as incomplete and inaccurate associated with inaccurate data entry, incorrect abbreviation, lack of knowledge to use it, and so on (Campanella et al., 2016). Such shortcomings threaten the safety of patient care. The is still a gap in comparing the impacts of both paper-based documentation and EHR that should be addressed via further studies. It is prudent to implement EHR in all healthcare facilities to exploit its benefits (Singh and Muthuswamy, 2013). However, paper-based can be used to complement the weaknesses of EHR for efficient care delivery. This information should reach both the private and government healthcare stakeholders to ensure that they put it into practice (Scruth, 2014). This can be done through public campaigns, publication, billboards, media channels, and other technological channels, including text messages and the internet (West et al., 2013).

Limitation of the Study

The study has many limitations. First, the study considered many types of study designs, including nonrandomized studies that are reportedly vulnerable to confounding by the self-selection of interventions, particularly psychological distress and comorbidities (Cartwright and Munro, 2010). Secondly, the review did not consider the commitment and determination of health care providers to the mastery and usage of EHR, particularly the elderly ones. Such negligence allows little consideration of other factors that impede the optimum effectiveness of nursing documentation (Fernando et al., 2012). Third, there were not enough papers covering a side-by-side comparison of EHR and paper-based records to be considered for the study. These limitations can compromise our conclusions.

Conclusion

Nursing documentation that combines both EHR and paper-based records is the most effective in increasing patient safety as per this review. The UK has made remarkable strides in its moves to implement EHR. This review calls for a renewed focus on the combined interventions identified as the most effective approach for better results as people move to be more acquainted with EHR. The UK should not flex in its quest for a complete shift to EHR since it is yet to achieve this goal. Not only the government should bear the responsibility of ensuring the achievement of this goal, but individuals as well. Individual care providers should develop the urge to adopt and use EHR in nursing documentation for better efficiency and storage. However, they can still use paper-record whenever necessary. All paper-based records should be transferred into EHR for safety reasons. The review proves both paper-based records and EHR should be used concurrently to enhance patient safety.

 

 

 

References

Akhu‐Zaheya, L., Al‐Maaitah, R. and Bany Hani, S., 2018. Quality of nursing documentation: Paper‐based health records versus electronic‐based health records. Journal of clinical nursing, 27(3-4), pp.e578-e589. https://doi.org/10.1111/jocn.14097

AL-ASWAD, A.M., BROWNSELL, S., PALMER, R. and NICHOL, J.P., 2013. A review paper of the current status of electronic health records adoption worldwide: the gap between developed and developing countries. Journal of Health Informatics in Developing Countries, 7(2). https://www.jhidc.org/index.php/jhidc/article/view/106

Albarrak, A.I., Al Rashidi, E.A., Fatani, R.K., Al Ageel, S.I. and Mohammed, R., 2014. Assessment of legibility and completeness of handwritten and electronic prescriptions. Saudi Pharmaceutical Journal, 22(6), pp.522-527. https://doi.org/10.1016/j.jsps.2014.02.013

Baumann, L.A., Baker, J. and Elshaug, A.G., 2018. The impact of electronic health record systems on clinical documentation times: a systematic review. Health Policy, 122(8), pp.827-836. https://doi.org/10.1016/j.healthpol.2018.05.014

Campanella, P., Lovato, E., Marone, C., Fallacara, L., Mancuso, A., Ricciardi, W. and Specchia, M.L., 2016. The impact of electronic health records on healthcare quality: a systematic review and meta-analysis. The European Journal of Public Health, 26(1), pp.60-64. https://doi.org/10.1093/eurpub/ckv122

Cartwright, N. and Munro, E., 2010. The limitations of randomized controlled trials in predicting effectiveness. Journal of evaluation in clinical practice, 16(2), pp.260-266. https://doi.org/10.1111/j.1365-2753.2010.01382.x

Coffey, C., Wurster, L.A., Groner, J., Hoffman, J., Hendren, V., Nuss, K., Haley, K., Gerberick, J., Malehorn, B. and Covert, J., 2015. A comparison of paper documentation to electronic documentation for trauma resuscitations at a level I pediatric trauma center. Journal of Emergency Nursing, 41(1), pp.52-56. https://doi.org/10.1016/j.jen.2014.04.010

Fernando, B., Kalra, D., Morrison, Z., Byrne, E., and Sheikh, A., 2012. Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: a systematic review. BMJ quality & safety, 21(4), pp.337-346. http://dx.doi.org/10.1136/bmjqs-2011-000450

Gatiti, P., Ndirangu, E., Mwangi, J., Mwanzu, A. and Ramadhani, T., 2021. Enhancing Healthcare Quality in Hospitals through Electronic Health Records: A Systematic Review. Journal of Health Informatics in Developing Countries, 15(2), p.1. https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1063&context=libraries

Hawley, G., Janamian, T., Jackson, C. and Wilkinson, S.A., 2014. In a maternity shared-care environment, what do we know about the paper hand-held and electronic health record: a systematic literature review? BMC pregnancy and childbirth, 14(1), pp.1-12. https://link.springer.com/content/pdf/10.1186/1471-2393-14-52.pdf

Hastings, C. and Fisher, C.A., 2014. Searching for proof: Creating and using an actionable PICO question. Nursing Management, 45(8), pp.9-12. https://doi.org/10.1097/01.NUMA.0000452006.79838.67

Hawley, G., Jackson, C., Hepworth, J., and Wilkinson, S.A., 2014a. Sharing of clinical data in a maternity setting: How do paper hand-held records and electronic health records compare for completeness? BMC health services research, 14(1), pp.1-9. http://dx.doi.org/10.1186/s12913-014-0650-x

Hyppönen, H., Saranto, K., Vuokko, R., Mäkelä-Bengs, P., Doupi, P., Lindqvist, M. and Mäkelä, M., 2014. Impacts of structuring the electronic health record: a systematic review protocol and results of previous reviews. International Journal of Medical Informatics, 83(3), pp.159-169. https://doi.org/10.1016/j.ijmedinf.2013.11.006

Hunter, S.C., Kim, B., Mudge, A., Hall, L., Young, A., McRae, P., and Kitson, A.L., 2020. Experiences of using the i-PARIHS framework: a co-designed case study of four multi-site implementation projects. BMC health services research, 20(1), pp.1-14. https://doi.org/10.1186/s12913-020-05354-8

Kruse, C.S., Kristof, C., Jones, B., Mitchell, E. and Martinez, A., 2016. Barriers to electronic health record adoption: a systematic literature review. Journal of medical systems, 40(12), pp.1-7. https://doi.org/10.1007/s10916-016-0628-9

Lavin, M.A., Harper, E. and Barr, N., 2015. Health information technology, patient safety, and professional nursing care documentation in acute care settings. Online J Issues Nurs, 20(2). https://doi.org/10.3912/OJIN.Vol20No02PPT04

McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett‐Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M. and Savage, E., 2019. Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of nursing management, 27(3), pp.491-501. https://doi.org/10.1111/jonm.12727

Neupane, S., Odendaal, W., Friedman, I., Jassat, W., Schneider, H., and Doherty, T., 2014. Comparing a paper-based monitoring and evaluation system to a mHealth system to support the national community health worker program, South Africa: an evaluation. BMC medical informatics and decision making, 14(1), pp.1-9. https://doi.org/10.1186/1472-6947-14-69

Nguyen, L., Bellucci, E. and Nguyen, L.T., 2014. Electronic health records implementation: an evaluation of information system impact and contingency factors. International journal of medical informatics, 83(11), pp.779-796. https://doi.org/10.1016/j.ijmedinf.2014.06.011

Nwagbo, E., 2018. Paper based Health Records or Electronic Health records? Linkedin. https://www.linkedin.com/pulse/paper-based-health-records-electronic-emmanuel-nwagbo/

Nwagbo, E., 2018a. Paper based Health Records or Electronic Health records? Linkedin. https://www.linkedin.com/pulse/paper-based-records-electronic-health-recordsehr-cont-emmanuel-nwagbo/

O’Connor, S. 2020. 5 Reasons Why Electronic Health Records are Better than Paper Records. ADVANCED DATA SYSTEMS CORPORATION. https://www.adsc.com/blog/reasons-why-ehr-software-is-more-secure-than-paper-based-records

Paans, W. and Müller‐Staub, M., 2015. Patients’ care needs: Documentation analysis in general hospitals. International journal of nursing knowledge, 26(4), pp.178-186. https://doi.org/10.1111/2047-3095.12063

Scruth, E.A., 2014. Quality nursing documentation in the medical record. Clinical nurse specialist, 28(6), pp.312-314. https://doi.org/10.1097/NUR.0000000000000085

Singh, B. and Muthuswamy, P., 2013. Factors affecting the adoption of electronic health records by nurses. World Applied Sciences Journal, 28(11), pp.1531-1535. https://doi.org/10.5829/idosi.wasj.2013.28.11.1899

Tsai, C.H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S. and Koch, S., 2020. Effects of electronic health record implementation and barriers to adoption and use: a scoping review and qualitative analysis of the content. Life, 10(12), p.327. http://dx.doi.org/10.3390/life10120327

UNC., 2022. Systematic Reviews. https://guides.lib.unc.edu/systematic-reviews/PRISMA

Wang, N., Yu, P. and Hailey, D., 2013. Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes. International journal of medical informatics, 82(9), pp.789-797. https://doi.org/10.1016/j.ijmedinf.2013.05.002

West, R., May, S., West, M., Croghan, E. and McEwen, A., 2013. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. Bmj, 347. https://doi.org/10.1136/bmj.f4921

Yu, P., Zhang, Y., Gong, Y. and Zhang, J., 2013. Unintended adverse consequences of introducing electronic health records in residential aged care homes. International journal of medical informatics, 82(9), pp.772-788. https://doi.org/10.1016/j.ijmedinf.2013.05.008

 

 

 

Appendices

Appendix 1: An Infographic comparing EHR and Traditional Paper Records

Appendix 2: A graph highlighting some of the disadvantages associated with EHR

Appendix 3: Demonstrating a scenario in which EHR is bringing convenience in two ho