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Can we have an electronic medical record for every American by 2014?

At my first job on an oncology unit, we used a traditional paper chart that was kept at the center of the unit. The only time the chart left the chart rack was when the patient left the floor or the physicians made rounds using the rolling chart rack. The nursing staff made notes of vital signs and medication administration on scraps of paper and transcribed the note into the chart at the end of the shift. Since this was an inefficient and often incomplete procedure, I proposed a pilot study using a bedside chart for documenting nurses' notes. The notes were transferred to the chart every 24 hours and were, in the meantime, accessible to any staff at the bedside. The pilot was successful and the charting procedure was changed throughout the hospital. Thankfully, those old ways are no longer needed.

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The Health Information Technology and Clinical Health Act (HITECH) was signed into law by President Obama in February 2009 as part of the American Recovery and Reinvestment Act. HITECH adds funds and clarification to the Office of the National Coordinator for Health Information Technology that was first established in 2004. A goal of this office is to create an electronic medical record for every person in the United States by 2014. To accomplish this goal, a nationwide health information technology infrastructure must be developed to ensure that patients' health information is secure and protected.

Politics aside, those who work in health care have strong feelings about what compliance with this law will mean in daily practice. For two decades I have heard about a paperless work environment, yet I find myself sorting, reading, filing, and managing more paper than ever. Until I can go anywhere at any time and have quick access to the Internet on a screen that is portable yet legible, I assume paper will follow me.

This month, oncology nurses discuss the challenges and benefits of electronic medical records. From a consumer perspective, I do not like the laptop in the examination room. Too often I am looking at the top of a head while being questioned about my symptoms and health concerns. I really do not like being asked the same questions two or three times in a row because the next person did not read what the previous person recorded. However, as a healthcare provider, when the patient has called with a symptom or problem, having access to the electronic medical record allows a rapid and informed response. In addition, care is facilitated when consultants and others have access to diagnostic test results and previous medical history.

I hope you will join the discussion in the next few years as we overcome the challenges to the goal of an electronic medical record for everyone by 2014.

[By Debra M. Wujcik, RN, PhD, AOCN[R], Editor]
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Article Details
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Author:Wujcik, Debra M.
Publication:ONS Connect
Article Type:Editorial
Geographic Code:1USA
Date:Oct 1, 2010
Words:474
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