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Electronic Health Records & Evidence-Based Medicine

Instructor: Maya Shapland

Maya has worked in the clinical, education, and management sections of healthcare for over 25 years and holds bachelor's degree in Speech and associate degree in Nursing.

Evidence-based medicine is the framework for making decisions in healthcare every day. This lesson will explain the foundation of evidence-based medicine, the electronic health record, and some of their practical uses.

Evidence-Based Medicine

Carolyn and her nursing team are caring for high-risk patients diagnosed with heart disease in their neonatal intensive care unit. It's an ever-changing environment requiring attention to detail and assessment skills that pick up the subtle changes in their patients.

Evidence-based medicine (EBM) uses information to make decisions that are based on scientific evidence, clinical expertise, and patient-family values. Carolyn can use her nursing assessments skills to determine patient needs and how she can approach her patient's families for learning opportunities prior to decisions being made.

Patient information is evidence-based to help the patients and families understand what the choices are and empower them to speak up for their own care management.

Components of EBM

EBM users include providers of healthcare such as physicians, nurses, other licensed practitioners, educators, and those formulating policy and procedures. Making this valuable information timely and accessible is where the electronic health record comes into play.

Electronic Health Records

Carolyn's newborn patient is having an abnormally fast heart rate called tachycardia. The use of evidence-based information gives the decision-makers more tools to make quality and timely decisions. Carolyn goes into the patient's record to find the link that explains possible causes of the tachycardia, medications, and treatments that may be used.

The needed information is embedded into the software used as the patient'selectronic health record (EHR). Clinicians can find the information linked and embedded in medication administration areas, physician orders, nursing notes and more, all with a click! Carolyn shares the plan with the patient's family so they are included on the team.

Medical or health records are becoming electronic all over the country and have added value for providers and patients alike. Here are a few examples of how EBM inside the electronic health record is working to everyone's benefit. EBM provides:

  • Disease information for clinicians and patients.
  • Choices of tests to order for a particular concern such as x-rays or ultrasound.
  • Potential risks to patients, for instance, side effects of tests or medications.
  • Choices for treatment to consider, for example, chemotherapy or radiation.
  • Structured paths like algorithms to determine best choices. These can help with decisions like a need for IV fluids, antibiotics the provider can consider, or fever control.

Algorithm for fever

Carolyn has found accessing the information for her clinical practice using the EHR has been a great timesaver. It's also helped her educate her patients' families with information like an x-ray procedure, preparation, and what to expect.

Potential Pitfalls

While the information from evidence-based medicine can be a great resource, there are some limitations to overcome in it's use. EBM may cause problems such as:

  • Keeping information current may require more staff.
  • Strong local commitment takes time and training.
  • Missing some issues with a particular problem that may require more research and provider wisdom.
  • Lapses in information available on clinical subjects.
  • Perceived threat to a clinician's way of practicing medicine.

Wherever the difficulties may be, EBM offers clinicians and policy-makers alike an opportunity to gain footing on the slippery slope of difficult decisions.

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