1. In an inpatient hospital environment, an EHR serves as a single point of access for clinical information about a patient. By integrating data from other hospital systems, such as pharmacy, laboratory, and radiology, the EHR provides caregivers with a complete and up-to-date picture of the patient’s condition and status. The primary function of an inpatient EHR is to assist in managing the transactions involved in a patient’s care, such as ordering diagnostic tests, viewing lab results, and administering medications, with the goal of improving quality and increasing patient safety.2. The primary benefits of hospital EHRs include (a) access to complete, up-to-date information about patients, including progress notes, results of laboratory tests and imaging studies, medication administration, and responses to treatment; (b) decreased turnaround time for medication delivery and completion of diagnostic tests; (c) increased efficiency by standardizing work processes and by integrating information from different departments; and (d) access to decision-support tools that help physicians make diagnosis and treatment decisions that provide patients with the safest, most effective care.3. Clinical documentation is used in an inpatient setting for many purposes, including (a) to assist in patient care planning and continuity of care; (b) to provide evidence of the course of the patient’s care and treatment during the hospital stay; (c) to facilitate communication among members of the patient care team; (d) to serve as a legal record to protect the interests of the patient, the hospital, and the clinician; (e) to supply data for research purposes; (f) to supply data for utilization review and quality improvement analysis and reporting; and (g) to provide information that enables coders to determine the appropriate diagnosis and procedure codes to substantiate patient billing.4. Computerized physician order entry (CPOE) eliminates errors that occur as a result of illegible handwriting by enabling physicians to enter patient orders using a computer. Electronic ordering is more efficient and also eliminates the possibility of losing or misplacing an order. Orders can be entered from any computer that has access to the hospital system. CPOE systems also contain decision-support tools that (a) provide alerts that warn against the possibility of drug interaction, allergy, overdose, and other problems; (b) provide accurate, up-to-date information on new medications, procedures, research, and so on; and (c) reduce costs by improving efficiency, eliminating duplicate tests, and reducing the number of lawsuits due to medication errors.5. Decision-support tools allow physicians to select medications, diagnostic tests, and treatments that result in improved quality of care and patient outcomes. Such tools can be used to select the best treatment based on evidence-based guidelines; to reduce variation in care by incorporating standard order sets; to alert the physician to possible drug interactions, improper dosages, and allergy conflicts during the ordering process; and to provide computerized access to up-to-date clinical research.6. When a physician orders a medication using CPOE, the order is automatically entered in the electronic medication administration records (eMAR). From that point on, the medication order and its administration are tracked by computer using barcode technology. The medication itself is labeled with a barcode by the pharmacy, and the patient has a wristband with a barcode. The nurse uses a handheld device to scan the label on the medication and on the patient’s wristband as part of the process of checking the five rights of medication administration.7. Electronic results reporting in an EHR has several advantages over traditional paper-based reporting systems, including faster turnaround time for results, which makes it possible for the physician to diagnose and treat the patient more efficiently. Consultations are more convenient, since clinicians can view the results from any computer with access to the EHR. Patients are given medications more quickly, since the orders are sent and received in less time. Electronic reporting also results in fewer duplicate tests, since the test is recorded in the EHR. Electronic results can be viewed in graphical format, which makes it easy to spot trends. Images and reports stored on a computer can be easily retrieved from any computer that has access to the EHR.
