The instructions for Writing 4 are: As you read your Difficult Reading Text 

Question The instructions for Writing 4 are: As you read your Difficult Reading Text , take notes on the places in which you encounter difficulty, what tools and strategies you use to get through, and if the tools and strategies are effective.   Take notes on the text on where difficulty was encountered and what writing strategies were used to help you get through. https://pubs.asha.org/doi/10.1044/2018_AJSLP-18-0062 Text Below – Electronic patient records as a tool to facilitate care provision in nursing homes: an integrative reviewIn recent decades, a change in demographic trends in Europe has led to an increasingly agingpopulation.1 Consequently, there has been a rise in the number of people being diagnosed with non-communicable diseases, such as dementia, which has placed new demands on the long-term care sector.2 An effective response to the challenge of delivering healthcare to an aging population may incorporate the introduction and utilization of appropriate technology,3-5 and the electronic patient record (EPR) is one technological solution that has been identified as potentially beneficial for facilitating the provision of care in a nursing home environment.6-8Healthcare today has been described as “information-intensive.”9 Consequently, completingdocumentation has become one of the most time-consuming activities for staff, meaning that they spend less time on delivering direct care.10 Furthermore, traditional, paper-based documentation is often inconsistent, incomplete, and illegible,11 as well as out-of-date and difficult to update.12 As a result, there is an increase in the possibility for errors and a reduction in the quality of care.13 In nursing homes, EPR systems may be used to record various nursing processes, such as assessment and care planning, and to write daily progress notes and handover forms.14 Potential benefits associated with using EPR include the effective management of chronic conditions,15 the collection of longitudinal information,8 and the ability to rapidly access information securely.8 Consequently, EPR may assist staff to deliver a more person-centered approach to care.16 Furthermore, the increased legibility and accuracyassociated with electronic documentation should result in a reduction in data errors and improvestandards of care.17 EPR also has the potential to lead to greater transferability of information across multiple stakeholders,17 allowing for a more integrated approach to care provision.18 Finally, EPR has also been associated with raising the “social standing of care work.”16Despite the potential benefits, the uptake of EPR in nursing homes has varied considerably across countries, with much of the literature referring to a “technology lag.”16,19,20 Furthermore, a previous systematic review of six studies exploring staff experiences with IT implementation in nursing homes found that the introduction of IT for documentation purposes may bring both benefits and burdens.21 Consequently, there have been calls to expand research to further examine the impact that electronic documentation systems have on working practices in nursing homes.9,15,22 Therefore, this literature review aims to add to existing knowledge in the field by exploring the impact of electronic documentation systems on the provision of care in nursing homes. MethodStudy designThe following literature review takes an integrative approach, synthesizing evidence from bothquantitative and qualitative studies. Although integrative reviews allow for the “inclusion of diverse methodologies,”they have been criticized for their lack of methodological rigor and bias.23 Therefore, Whittemore and Knafl suggest a specific framework for carrying out integrative reviews, influenced by the model developed by Cooper24 for conducting systematic reviews and meta-analyses. This frame- work is used below to describe the process of data collection, analysis, and synthesis.Search strategy Various terms can be found in the literature to refer to technology used to record patient data digitally, which are often used interchangeably.25 For example, in their systematic review, Häyrinenet al.26 found the following common terms: electronic health records (EHR), EPR, and electronic medical records (EMR). The terms EPR and EMR have the same meaning, with EPR more commonly seen in the United Kingdom, and EMR used in the United States. An EPR or EMR is defined as an application that is “composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications”and refers to information collected from one organization.25 Whereas an EHR refers to a broader application, which brings together longitudinal data from an individual’s various EPRs from different healthcare organizations.25 Likewise, the terms nursing home and long-term care are often considered synonymous. In the United Kingdom, introduced in response to “public policy designed to minimise the use of acute hospitals,”27 nursing homes address the more complex medical needs of individuals, including personal care needs.2 The World Health Organization defines long-term care as “the system of activities undertaken by informal caregivers and/or professionals to ensure that a person who is not fully capable of self-care can maintain the highest possible quality of life.”28 One “apparatus”of long- term care is “care in an institutional setting,”such as a nursing home.2 In order to obtain as many relevant results as possible, the terms “electronic medical records,” “electronic patient records,””electronic health records,”as well as the more general term “electronic documentation,”have been combined with the terms “nursing home”and “long-term care.”Four databases were used to search for articles. Table 1 shows the exact search string used for each database, along with the number of articles that resulted from the searches. Data analysisThematic synthesis was used as a method of data analysis.30 Both the results and discussion sections of the 22 articles were coded inductively by hand line by line, which presented emerging themes across the literature. This process was carried out until saturation of themes was reached. Similarities across themes were then searched for and several were merged and renamed leaving 10. The final stage of thematic synthesis, “generating analytical themes,”30 involved synthesizing these 10 existing themes in order to address the research question directly, leaving the following 6 analytical themes: time for direct care, accountability, assessment and care planning, exchange of information, risk awareness, and person-centered care. Table 2 summarizes the articles used for thematic synthesis.ResultsTime for direct careA number of studies reported that the introduction of an electronic documentation system allowed staff to spend less time on documentation, meaning that they had more time for direct care.5,19,31-33 Staff find using a computer for documentation faster than filling out forms by hand. Furthermore, staff can quickly move from one resident’s record to another, and multiple staff members are able to access records at the same time.32 The processes of data distribution, storage, and retrieval were also described as more efficient,5,19,31,32,34-36 and the presence of a spellcheck saves time on proofreading.37 Moreover, increased legibility has meant that staff are no longer forced to call doctors to clarify information that was previously handwritten, often causing time delays.35 Florczak et al.33 found that portable, handheld devices increased efficiency as they enabled staff to access and record data at the point of care. However, in a separate study, some staff felt that bedside technology was time-consuming, and as a result, they were found to be documenting at the end of their shift, and some documenting before care had been provided.38 In several other studies, it was also suggested that electronic documentation systems do not necessarily save staff time19,22,36,38 forreasons such as slow log-in processes,9,14 difficulties with updating passwords,35 and having to access each resident’s record individually to chart information as opposed to using one paper chart for all residents.37 In one home, the reporting of incidents required staff to document information into the electronic record and into a separate software system, increasing overall time spent on incident reporting. AccountabilityDocumented evidence of care is essential for managers to “assess whether care [. . .] was professional, safe and competent.”13 In four studies, senior staff highlighted that they are more able to monitor the quality of care provision with an electronic documentation system.5,19,31,34 Electronic documentation also enables managers to identify “patterns and trends in care needs and evaluate outcomes of care,”13 increasing their knowledge about the current health status of residents in their homes.5,19 However, in a study by Yu et al.,37 participants stated that they were not able to easily generate trends from data and require an application that could automatically produce graphs and generate reports. As regards to external audits, staff found that they were able to record the minimum data set (MDS) more accurately with EHR.38 Furthermore, electronic records make it easier to extract relevant information from documentation, allowing inspectors to carry out the audit process with “greater consistency and regularity.”19 One study described the use of iButtons, a device designed to increase accountability, which the staff found “inconvenient and bothersome.”38 iButtons should be worn by residents and staff, and allow for the “verification of caregiver activities”at the point of care.38 However, in the home in this study, residents were often found not to be wearing iButtons and staff had to search for them, causing delays in the documentation, and showing the incorrect time for care delivery. Furthermore, when residents were wearing the iButtons, staff felt that touching the buttons disturbed them. Participants from this study also expressed concern that the increased monitoring of care delivery was making them feel “watched.”Although others believed that monitoring would lead to their work being “recognized.”38 Assessment and care planning Across several studies, caregivers’perceptions of using electronic documentation for assessment and care planning were positive.5,19,33 Staff believe that some electronic assessment templates are more thorough as they provide prompts to identify potential problems,19 whilst also guiding nurses “through body systems.”19 Participants in the study by Zhang et al.5 noted that the interface for assessments popped up as soon as a staff member logged in, which enabled them to start with the task as quickly as possible. As regards to advance directives, an electronic intervention implemented into an EHR, designed to encourage documentation of patient wishes regarding life-sustaining care, increased the rate of advance directive discussion notes significantly.39 This was linked with improved accessibility to this section of the care plan as the link was “uniformly placed”within notes, appearing at the top of the patient order list and labeled “code status.”39 Staff from one study also felt that electronic documentation facilitated the writing of care plans because they are more able to access assessment forms and other relevant information and “think more critically”when developing a care plan.5 In particular, staff appreciate being able to switch between documents and copy and paste information.5 Using laptop computers that contain resident information during care planning meetings is also beneficial.32 Furthermore, participants widely reported that electronic systems generate more accurate, complete, consistent, and legible informa-tion than paper records5,13,14,19,31,33-36,38 and highlighted that their quality does not deteriorate over time like paper records.5 However, several studies indicated that electronic documentation systems may not necessarily facilitate care planning and assessment.13,37,38,40-42 For example, Wang et al.42 carried out an audit study with results suggesting that electronic care plans provided less information about resident diagnosis and outcomes than paper-based records. However, this lack of information was linked with a possible issue with the wording of the data fields, which did not encourage nurses to “formulate diagnosis statements.”42 Other sources of frustration included having to enter unnecessary information, but not having space in data fields for free text.35,37,38 Furthermore, staff found that necessary forms were missing from the system.37,38 In one study, frustrations with unsuitable electronic forms led staff to usingshortcuts; in this case, documenting data in free text as opposed to using the forms. However, this meant that information was not standardized and prevented the automatic population of data into reports for trending purposes.38 Suggestions for improvements to systems included a function where staff could enter a keyword and jump to the right section in a resident’s notes, and care plans that could be automatically generated from assessment data.5,36,37Exchange of informationThere were mixed results as to whether electronic documentation facilitated an exchange ofinformation. Issues with external communication were described in one home where staff wererestricted from accessing the electronic hospital records of patients who were about to be discharged from the hospital to their nursing home. This meant that hospital staff would fax or send printed hardcopies of electronic records, which were often incomplete, causing time to be lost in contacting the hospital to clarify information.35 Munyisia et al.13 also found that staff did not believe that the introduction of an electronic documentation system had improved communication within the home. This could be linked to slow log-in processes, which in a separate study led staff to avoid recording information electronically.9 However, staff may also be reluctant to change their established means of communication. In two studies, participants reported that they preferred to communicate information about residents verbally within the home.5,37 Moreover, in one study where there had been a reduction in face-to- face communication, staff were concerned about losing “a sense of belonging.”37 Positive ways in which electronic documentation facilitates an exchange of information within the nursing home include the instant availability of records,5,36 which is particularly helpful for staff whohave been on leave and need to catch up on notes quickly.5 Furthermore, it allows for immediateaccess to initial resident assessments so that “correct care”can start straight away.5 Electronicdocumentation systems may also facilitate an exchange of information outside of the home. Inone study, it was described how a camera built into the electronic device allowed staff to take photos of wounds.33 These photos could be uploaded to residents’records and accessed by external healthcare providers who could then make a remote diagnosis or clinical decision. Staff also found that they could communicate better with physicians38 and provide more detailed information to families due to the immediate accessibility of records through an electronic system.19,32Risk awarenessThe comprehensive and standardized nature of electronic records are reported to increase the “visibility” of changes in health,35,38 allowing senior staff to “more quickly identify resident care needs.”31 Particularly valuable are applications that can trend clinical problems and produce alerts about new resident events, which direct staff to provide appropriate care.19 For example, in one study, improve-ments were seen in both the decline of range of motion and in high-risk pressure sores following the implementation of a bedside EMR, which prompted required care.43 An electronic wound documentation system as investigated by Florczak et al.33 was also found to more effectively manage treatment of wounds, promote healing, and enable staff to better recognize changes in wounds. However, nurses did not feel that the system had a significant influence on preventing avoidable wounds from initially occurring, although the authors note that this may be linked to staff not fully implementing the “risk functionality”element.33 Likewise, in another study, alerts were not always utilized,and furthermore, the importance of updating alerts with “best practice information”was highlighted.38 Two studies specifically described the effect of a computer decision support system (CDSS) embedded in an electronic system. Fossum et al.44 found that documentation completed by staff in the intervention group using a CDSS was significantly more and comprehensive in recording “the risk and prevalence of [pressure ulcers] and malnutrition.”However, it should be noted that this group were exposed to two simultaneous interventions. In a separate study, Alexander15 found that alerts produced by a CDSS to warn staff about “potential skin breakdown”did not lead to a significant increase in the recording of clinical responses in most types of documentation, except for turning and repositioning charts for residents. Data from electronic records may also increase the prediction of fall risk in comparison to data from the MDS alone, linked with the “increased frequency with which EMR data are updated”in comparison to MDS data.45 Another possible benefit of an electronic documentation system is the ability to manage behavior more effectively.5 In one study, staff described how due to the improved accessibility of information they were more able to “analyse common occurrences of certain undesirable behaviours”and understand why they may have occurred.5 This allowed staff to avoid potential triggers when interacting with residents, reducing incidents of undesirable behaviour.5Person-centered careIn the study by Zhang et al., staff reported that electronic documentation facilitated person-centered care as they were more able to access information about an individual’s past, as well as their current needs, which gives a “broader and more holistic view”of an individual.5 The electronic record system also allowed for the storage of photos of residents, which new staff found to be a helpful tool for learning residents’names, and access to additional information provided new staff with a topic of conversation for when they met with residents for the first time.5 Meehan35 reported that staff in one home found it difficult to share discharge plans and care instructions with those patients and their families who were only in the home for rehabilitation purposes. They suggested that the introduction of a portable device would act as a tool to take into resident’s rooms and visually show the patient their care plan, as well as web tutorials relating to relevant aspects of care provision.35 Participants from the same study also believed that mobile devices would allow them to have improved access to vital information about a resident’s needs, for example allergies, which is particularly important for those individuals who are only staying in the home for a short time, or for staff who work infrequently in the home.DiscussionThis integrative review has explored the ways in which EPR is facilitating or hindering care provision in nursing homes. The results of this review suggest that EPR may have the potential to assist staff in the provision of care in nursing homes. However, results have also highlighted that in order for this to occur there are certain requirements that should be considered as regards to the type of device and applications used for electronic documentation, as well as the functionality, structure, and content of EPR. These are summarized in Table 3 and subsequently described.Device and applicationsA number of studies in this review highlighted the importance of technology that can be accessed at the point of care.22,33,36,37 This echoes results from a study by Chau and Turner,46 who explored nursing home staff’s experiences with using mobile, handheld technology. They found that the quantity and quality of documentation improved with the use of a mobile device, and that documenting information at the point of care was less time-consuming. Furthermore, in this review, portable devices were described as particularly useful for providing person-centered care.5,35 However, as found by Rantz et al.,38 introducing devices for bedside documentation has the potential to create burdensome expectations for staff, and as a result, they may be reluctant to record documentation. Another device considered burdensome by staff was iButtons.38 Although this device promoted accountability, developers should also take into account that devices do not disturb or invade residents’privacy, or make staff feel watched.Florczak et al.33 highlighted the benefits of portable devices with cameras that enable staff to take photos of wounds, which can easily be shared with relevant external healthcare providers, who can then suggest appropriate care. As regards to applications for EPR systems, a spell check, a copy and paste function, as well as a function to enter a keyword to search for specified information within records were all identified as saving staff time.5,36,37 Secure log-in processes should also allow for quick access to records so that staff are not prevented from accessing information prior to care delivery.9FunctionalityMunyisia et al.22 argue that electronic documentation systems should act as more than “a repository of information”and prompt staff about changes in residents’condition. A CDSS embedded into a system may be useful in alerting staff to potential risk factors and enable them to provide the correct care accordingly. However, the two studies used in this review that explored CDSS did not conclusively support such an application for increased documentation of clinical responses15 or improved documentation of ulcer and malnutrition-related assessments and interventions.44 Furthermore, it is important that alerts are consistently updated in line with good clinical practice in order to support evidence-based practice in nursing homes,44 and that the CDSS is user-friendly.47 Participants also thought that alerts that prompt staff to create or update a document would be useful and highlighted the need for the EPR to generate care plans from assessment data, as well as to create graphs from data to produce trending reports.37Another common requirement identified across the studies was the need to be able to share and access information externally.33,35,38 The transferability of information is particularly important in the long-term care sector as patients are frequently transferred from hospitals to nursing homes and effective transitions of care are required.48 The lack of ability to share information across care providers has been described as “the largest limitation factor”of electronic records.49 Widely introduced in Canada, interoperable EHRs are “a secure consolidated record of an individual’s health history and care, designed to facilitate authorised information across the care continuum.”50 Ensuring interoperability of future EPR systems is particularly important as information gaps in long-term care have been shown to have consequences for patients, clinicians, and the healthcare system.48Structure and contentOne of the principal reasons for the introduction of electronic records was to improve the quality of documentation, specifically assessments and care plans.13,42 However, Wang et al.42 found that staff were documenting less information relating to the nursing problem and resident outcomes. This was linked to possible flaws in the language used to prompt staff to record information. Furthermore, a lack of appropriate forms meant that staff in one study were found to be adding notes in free text, preventing the automatic population of data into reports.38 Therefore, as well as including the appropriate forms for the environment, developers should ensure systems allow for a structured form of data entry with “formalised nursing language,”42 which will also mean that decision-making tools can be successfully integrated into EPRs.26Nurses also identified the importance of structured templates for assessment purposes19 and links to important documents that should be accessible and “uniformly placed.”39 In addition, the EPR should allow for the detailed collection of information about a resident’s background. Such informa-tion was highlighted as being particularly important for new staff whilst they are becoming acquainted with residents,5 but may also act as a useful source of information for staff who work infrequently in the home. Furthermore, person-centered care is an integral part of dementia care,51 and access to a detailed history may improve staff’s understanding of a resident’s behavior and how to respond appropriately.5LimitationsLimitations of this study include the nature of integrative reviews, which are complex due to the way in which they combine studies with diverse methodologies, potentially leading to bias.23 This study has used the PRISMA guidelines29 in order to increase transparency and reduce bias. However, the synthesis of qualitative and quantitative research is a developing area and currently lacks explicit guidance.52 Restrictions to articles in either English or French may have meant some studies were not included, and as Google Scholar was not used in the search, additional gray literature may have been missed, which could have provided a wider insight into the topic. Finally, a number of issues relating to implementation of EPR were raised in many of the articles used in this research. However, this review has not focused on these issues as they have been described in detail in numerous other studies.21,53,54ConclusionOne of the principal reasons for the introduction of EPR into nursing homes was to assist staff to provide care.6,7,41 However, findings of this review have shown that several aspects relating to the EPR system are hindering care provision in nursing homes, and that consideration should be given to numerous factors linked to the device, applications, structure, content, and functionality. Within the literature used for this review, there were some references to the technology that staff are currently using to document information electronically, as well as suggestions for modifications to existing technology that would increase usability. However, more research is required to identify the optimal characteristics of an EPR system for use in a nursing home environment, and in particular, research that focuses on the end user’s experience of EPR.  Health Science Science Nursing ENGLISH 1A Share QuestionEmailCopy link Comments (0)