an electronic health record (EHR) system is how to fill it with patient data. What data should be entered, who should enter it, and when should it be done? I’ve seen many strategies tried, and in my experience the ideal solution is to have patients enter as much data as possible themselves before beginning a patient visit. This saves physicians time and can even lead to higher-quality data. Aft...

Healthcare is an information intensive industry, yet Information and Communications Technologies (ICT) have been unable to infiltrate this sector successfully. With the growing trend towards a virtual health record, the healthcare sector is now trying to implement the electronic health record, which would contain all health and healthcare information relating to each patient. The aim of this pa...

Many functions important to realizing the full potential from electronic health records (EHRs) may not be selected by all physicians using EHRs in the ambulatory setting. This article examines the extent to which EHR systems used by Florida physicians include functionalities that the Institute of Medicine has designated as being critical for optimal performance. Results indicate that EHR system...

Increasing numbers of patients have direct access to their electronic health records (EHRs). Proponents of direct access argue that it empowers patients by making them more informed and offering them more control over their health and care. According to some proponents of patients' access to EHRs, clinicians' concerns about potential negative implications are grounded in a form of paternalism t...

OBJECTIVE This study was conducted to describe the current content and context of change of shift report (CoSR) on medical and surgical units and explore whether nurses use computerized support during the CoSR process. BACKGROUND Change of shift report is a commonly occurring handoff that could contribute to gaps in care. METHODS Bedside, face-to-face, and audiotaped CoSRs were audiotaped a...

As the health system continues to evolve through the implementation of the electronic health record and other information technology initiatives, it is imperative that governments undergo a paradigm shift and recognize the need for strategic investment in home care (CHCA 2008a:7).

OBJECTIVE To understand how nurses respond to alerts that detect attempts to enter into electronic health records patient weights that vary significantly from previously recorded weights. METHODS Examination of subsequent patient weights to determine if the alerts were true positive (TP) or false positive (FP), and whether nurses overrode alerts, changed their entry or quit without storing a ...

BACKGROUND Fractures are common in childhood, and there is considerable variation in the reported incidence across European countries, but few data relating to ethnic and geographic differences within a single country. We therefore aimed to determine the incidence of childhood fractures in the United Kingdom (UK), and to describe age-, ethnicity- and region- specific variations. METHODS The C...

A fundamental premise of scientific research is that it should be reproducible. However, the specific requirements for reproducibility of research using electronic health record (EHR) data have not been sufficiently articulated. There is no guidance for researchers about how to assess a given project and identify provisions for reproducibility. We analyze three different clinical research initi...

Physician-patient communication is becoming increasingly complicated with the growing use of electronic health records (EHRs). While the EHR has shown benefits in some aspects of medical care, these improvements are often at the expense of patient-centered communication. Below are some reflections on this topic, as well as techniques to improve the clinician-patient interaction in the EHR era.