PDF herunterladen
Appl Clin Inform 2021; 12(01): 027-033
DOI: 10.1055/s-0040-1721013
Research Article

Electronic Health Records in Danish Home Care and Nursing Homes: Inadequate Documentation of Care, Medication, and Consent

Morten Hertzum
1   Department of Communication, University of Copenhagen, Copenhagen, Denmark
› Institutsangaben Funding None.
› Weitere Informationen
   Lizenzen und Reprints

Abstract

Background Electronic health records (EHRs) are used in long-term care to document the patients' condition, medication, and care, thereby supporting communication among caregivers and counteracting adverse drug events. However, the use of EHRs in long-term care has lagged behind EHR use in hospitals. In addition, most EHR research focuses on hospitals.

Objective This study gives a countrywide status of the documentation-related risks to patient safety in Danish home care and nursing homes, which are the two main providers of long-term care. Such a status provides a basis for national improvement efforts and international comparisons.

Method The study is based on the reports from 893 inspections of home care and nursing homes by the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed [STPS]).

Results As much as 69% of the inspected institutions document inadequately to an extent that has led to demands (i.e., issues the institution is legally obliged to rectify) or requests (i.e., issues the institution is merely asked to rectify) from STPS. Documentation issues about the patients' condition and care are present in nearly all institutions that receive demands (97%) and in the majority of those that receive requests (68%). Documentation issues about medication and consent to care are also common, but less so. The predominant risk to patient safety is incomplete documentation. It covers 72% of the documentation issues identified in the institutions that received demands; the remaining risks concern inconsistent (11%), nonexistent (7%), inaccessible (5%), and noncompliant (5%) documentation. The documentation inadequacies are similar for home care and nursing homes.

Conclusion Inadequate EHR documentation is a widespread problem in Danish long-term care. While previous research mainly focuses on how EHR documentation affects patient medication, this study finds that documentation issues about the patients' condition and care are more prevalent and that issues about their consent are also common.

Keywords

electronic health record - patient-safety risk - long-term care - home care - nursing home

Protection of Human and Animal Subjects

This study analyzes publicly available documents. It does not include human or animal subjects.




Publikationsverlauf

Eingereicht: 09. Juni 2020

Angenommen: 08. Oktober 2020

Artikel online veröffentlicht:
13. Januar 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Harris-Kojetin L, Sengupta M, Lendon JP, Rome V, Valverde R, Caffrey C. Long-term care providers and services users in the United States, 2015–2016. Vital Health Stat 2019; 3 (43) 1-78
    PubMedGoogle Scholar
  • 2 Leichsenring K, Billings J, Nies H. eds. Long-Term Care in Europe: Improving Policy and Practice. New York: Palgrave Macmillan; 2013
    CrossrefGoogle Scholar
  • 3 Lum T. Long-term care in Asia. J Gerontol Soc Work 2012; 55 (07) 563-569
    CrossrefPubMedGoogle Scholar
  • 4 Phillips K, Wheeler C, Campbell J, Coustasse A. Electronic medical records in long-term care. J Hosp Mark Public Relations 2010; 20 (02) 131-142
    CrossrefPubMedGoogle Scholar
  • 5 Kruse CS, Mileski M, Vijaykumar AG, Viswanathan SV, Suskandla U, Chidambaram Y. Impact of electronic health records on long-term care facilities: systematic review. JMIR Med Inform 2017; 5 (03) e35
    CrossrefPubMedGoogle Scholar
  • 6 Bjarnadottir RI, Herzig CTA, Travers JL, Castle NG, Stone PW. Implementation of electronic health records in U.S. nursing homes. Comput Inform Nurs 2017; 35 (08) 417-424
    CrossrefPubMedGoogle Scholar
  • 7 Heimly V, Grimsmo A, Faxvaag A. Diffusion of electronic health records and electronic communication in Norway. Appl Clin Inform 2011; 2 (03) 355-364
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 8 Magrabi F, Aarts J, Nøhr C. et al. A comparative review of patient safety initiatives for national health information technology. Int J Med Inform 2013; 82 (05) e139-e148
    CrossrefPubMedGoogle Scholar
  • 9 De Vliegher K, Paquay L, Vernieuwe S, Van Gansbeke H. The experience of home nurses with an electronic nursing health record. Int Nurs Rev 2010; 57 (04) 508-513
    CrossrefPubMedGoogle Scholar
  • 10 Gershater MA, Pilhammar E, Roijer CA. Documentation of diabetes care in home nursing service in a Swedish municipality: a cross-sectional study on nurses' documentation. Scand J Caring Sci 2011; 25 (02) 220-226
    CrossrefPubMedGoogle Scholar
  • 11 Gjevjon ER, Hellesø R. The quality of home care nurses' documentation in new electronic patient records. J Clin Nurs 2010; 19 (1-2): 100-108
    CrossrefPubMedGoogle Scholar
  • 12 Ibrahim S, Donelle L, Regan S, Sidani S. A qualitative content analysis of nurses' comfort and employment of workarounds with electronic documentation systems in home care practice. Can J Nurs Res 2020; 52 (01) 31-44
    CrossrefPubMedGoogle Scholar
  • 13 Nilsson M, Hertzum M. Negotiated rhythms of mobile work: time, place, and work schedules. In: Proceedings of the GROUP2005 Conference on Supporting Group Work. New York: ACM Press; 2005: 148-157
    PubMedGoogle Scholar
  • 14 Sockolow PS, Bowles KH, Adelsberger MC, Chittams JL, Liao C. Challenges and facilitators to adoption of a point-of-care electronic health record in home care. Home Health Care Serv Q 2014; 33 (01) 14-35
    CrossrefPubMedGoogle Scholar
  • 15 Hitt LM, Tambe P. Health care information technology, work organization, and nursing home performance. Ind Labor Relat Rev 2016; 69 (04) 834-859
    CrossrefPubMedGoogle Scholar
  • 16 Meehan R. Electronic health records in long-term care: staff perspectives. J Appl Gerontol 2017; 36 (10) 1175-1196
    CrossrefPubMedGoogle Scholar
  • 17 Munyisia EN, Yu P, Hailey D. The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. Int J Med Inform 2011; 80 (02) 116-126
    CrossrefPubMedGoogle Scholar
  • 18 Pillemer K, Meador RH, Teresi JA. et al. Effects of electronic health information technology implementation on nursing home resident outcomes. J Aging Health 2012; 24 (01) 92-112
    CrossrefPubMedGoogle Scholar
  • 19 Tuinman A, de Greef MHG, Krijnen WP, Paans W, Roodbol PF. Accuracy of documentation in the nursing care plan in long-term institutional care. Geriatr Nurs 2017; 38 (06) 578-583
    CrossrefPubMedGoogle Scholar
  • 20 Voyer P, McCusker J, Cole MG. et al. Nursing documentation in long-term care settings: new empirical evidence demands changes be made. Clin Nurs Res 2014; 23 (04) 442-461
    CrossrefPubMedGoogle Scholar
  • 21 Yu P, Zhang Y, Gong Y, Zhang J. Unintended adverse consequences of introducing electronic health records in residential aged care homes. Int J Med Inform 2013; 82 (09) 772-788
    CrossrefPubMedGoogle Scholar
  • 22 Shiells K, Holmerova I, Steffl M, Stepankova O. Electronic patient records as a tool to facilitate care provision in nursing homes: an integrative review. Inform Health Soc Care 2019; 44 (03) 262-277
    CrossrefPubMedGoogle Scholar
  • 23 Qian S, Yu P, Hailey DM. The impact of electronic medication administration records in a residential aged care home. Int J Med Inform 2015; 84 (11) 966-973
    CrossrefPubMedGoogle Scholar
  • 24 Wang N, Yu P, Hailey D. The quality of paper-based versus electronic nursing care plan in Australian aged care homes: a documentation audit study. Int J Med Inform 2015; 84 (08) 561-569
    CrossrefPubMedGoogle Scholar
  • 25 Munyisia EN, Yu P, Hailey D. Does the introduction of an electronic nursing documentation system in a nursing home reduce time on documentation for the nursing staff?. Int J Med Inform 2011; 80 (11) 782-792
    CrossrefPubMedGoogle Scholar
  • 26 Cheevakasemsook A, Chapman Y, Francis K, Davies C. The study of nursing documentation complexities. Int J Nurs Pract 2006; 12 (06) 366-374
    CrossrefPubMedGoogle Scholar
  • 27 Østensen E, Bragstad LK, Hardiker NR, Hellesø R. Nurses' information practice in municipal health care-a web-like landscape. J Clin Nurs 2019; 28 (13-14): 2706-2716
    CrossrefPubMedGoogle Scholar
  • 28 de Veer AJE, Francke AL. Attitudes of nursing staff towards electronic patient records: a questionnaire survey. Int J Nurs Stud 2010; 47 (07) 846-854
    CrossrefPubMedGoogle Scholar
  • 29 Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15 (09) 1277-1288
    CrossrefPubMedGoogle Scholar
  • 30 Danish Patient Safety Authority. Accessed November 18, 2019 at: https://stps.dk
    PubMedGoogle Scholar
  • 31 Wang N, Yu P, Hailey D. Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes. Int J Med Inform 2013; 82 (09) 789-797
    CrossrefPubMedGoogle Scholar
  • 32 Zhang Y, Yu P, Shen J. The benefits of introducing electronic health records in residential aged care facilities: a multiple case study. Int J Med Inform 2012; 81 (10) 690-704
    CrossrefPubMedGoogle Scholar
  • 33 Bao Y, Shao H, Bishop TF, Schackman BR, Bruce ML. Inappropriate medication in a national sample of US elderly patients receiving home health care. J Gen Intern Med 2012; 27 (03) 304-310
    CrossrefPubMedGoogle Scholar
  • 34 Jones W, Drake C, Mack D, Reeder B, Trautner B, Wald H. Developing mobile clinical decision support for nursing home staff assessment of urinary tract infection using goal-directed design. Appl Clin Inform 2017; 8 (02) 632-650
    Artikel in Thieme ConnectPubMedGoogle Scholar