This content origi­nally appeared in the Spring/​Summer 2020 issue (PDF) of The Washington Nurse magazine. See the full set of stories on long-term care.

Wa nurse records

As nurses, we recog­nize that long-term care is not merely a place people reside but also a status during their lives. While it is apparent that most people are in the care of others from birth to death, nurses especially focus on improving the outcomes for the patients, their families and the caregivers who reside within a long-term care paradigm.

I currently work as a nurse in an emergency room, focused on the acutely ill. A high percentage of our patients arrive from skilled nursing facil­i­ties, from adult family homes or from their own homes, where they may be cared for by family members or agency caregivers. It is very challenging to assess their needs as they frequently arrive without any details beyond their own recol­lec­tion or those of emergency medical service respon­ders. Medical histo­ries, medica­tion records and POLSTs (Physi­cian Orders for Life-Sustaining Treat­ment) are frequently missing or absent from their records. If a family member accom­pa­nies, they sometimes have a copy of the durable power of attorney, but rarely is there a complete, up-to-date list of medica­tions. Fortu­nately, pharmacy records are more likely to be in the patient’s database than most other infor­ma­tion. Written, let alone oral (via phone), handoffs from other RNs via SBAR (Situa­tion Background Assess­ment Recom­men­da­tion) are very rare. The best skilled nursing facil­i­ties follow up later, but usually, if infor­ma­tion is missing, we must call the caregivers for clari­fi­ca­tion. Some patients arrive without any infor­ma­tion, even lacking the name of the facility from which they came. All of this compli­cates and delays treatment.

It is rare for anyone in the health care system not to have their medical infor­ma­tion in electronic form. Access to the patient’s electronic health record should be avail­able to those providing health care in appro­priate settings. There are examples of such systems in place in other areas of the world. For example, Denmark has a central­ized computer database acces­sible to 98% of primary care physi­cians, all hospital physi­cians and all pharma­cists. Danish residents can gain access to their own records through a secure website. However, the country’s health care is run by the public sector. Finland and the Nether­lands have over 95% of citizen records avail­able. Canada and Australia have much greater geographic and cultural diver­sity of their residents, but both are making great strides. The National Health Service in the UK report­edly still has many platforms but is making progress toward a unified electronic health record system. Insti­tu­tions of varying complexity could add elements to the chart based primarily on their needs and secon­darily on their resources.

The federal govern­ment would be the appro­priate leader to initiate a national electronic health records system. It would be a huge under­taking — of money and resources. One possible source of funding could be a tax on the pharma­ceu­tical industry, especially since the database would poten­tially include up to 330 million patients. The central­ized storage of records would require a valid and reliable design, created to reduce chances of hacking or being compro­mised. Limits on how the infor­ma­tion could be accessed by industry and prohi­bi­tions of adver­tising on the platform would be neces­sary to ensure relia­bility, public buy-in and lack of bias for providers and consumers. Security, including adequate encryp­tion, is vital and avail­able using two-factor authentication.

In addition to infor­ma­tion about health care provider visits and changes in medica­tion records, it would be benefi­cial to include imaging, lab work, assess­ments and patient direc­tives. All infor­ma­tion could all be avail­able and updated from any secured computer by a licensed health care profes­sional using two-factor authentication.

There are many gains from such a system. A large complete record of all of us would be avail­able wherever we travel or move in the U.S., making available:

  1. Clear, concise direc­tives by the patient or their legal representative.
  2. Rapid access to the most recent data on the patient.
  3. A complete, current medica­tion list, including dosages.
  4. The ability to quickly update the record for other health care providers.

The downside is cost and poten­tial hacks to the system (minimized with two-factor authen­ti­ca­tion), and, polit­i­cally, many people are worried about protecting their infor­ma­tion and who has access to it.