EFFECTS OF EHR AND USE OF THE MAR ON PATIENT CARE 1

Effects of Electronic Health Records and use of the MAR on Amount of Nursing Errors and

Quality of Patient Care

Jessica Goist, Makaela Giannini, Nicholas Petro, Paige Poznar, and Hayley Socha

Youngstown State University

NURS 3749: Nursing Research

Dr. Valerie O’Dell

04/07/2021
EFFECTS OF EHR AND USE OF THE MAR ON PATIENT CARE 2

Abstract

The purpose of this research was to examine how use of Electronic Health Records and the

Medication Administration Record have impacted both patient care and the quantity of nursing

errors in the duration of patients’ hospital stays. The correlation between quality of patient care

upon use of electronic documentation was explored, as well as the occurrence of nursing errors

with respect to the Medication Administration Record. This research was collected from ten

scholarly articles and literature reviews, some of which included qualitative or quantitative

studies. It was concluded that electronic documentation allowed for improved nursing care of

patients, as well as significant decreases in the number of errors performed by nurses in the

hospital setting with the addition of the MAR.

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Effects of Electronic Health Records and use of the MAR on Amount of Nursing Errors and

Quality of Patient Care

The use of technology in hospitals has increased drastically over the years and continues

to increase. Electronic health records (EHRs) allow care providers to quickly access organized

and up to date medical health records. With the use of the electronic medication administration

record (MAR), health care professionals can chart and view the record of all medications

administered to a patient. Studies show that EHRs and the electronic MAR compared to paper

charting allows for more effective continuity of care and interprofessional collaboration, while

also decreasing the risk of medical errors.

Literature Review

Throughout the literature review, the accuracy and effectiveness of EHRs and the MAR

will be compared to paper charting. Ten sources were analyzed for evidence supporting the use

of EHRs and the MAR over paper charting. The following topics will be discussed: multiple

chronic conditions, interprofessional collaboration, patient safety, pressure ulcer documentation,

documentation quality, continuity of health care, and medication error in relation to EHR and

MAR.

Documentation Quality

High-quality documentation is critical in order to ensure safe and effective medical care.

Likewise, accurate documentation is utilized to guide other care team members with tasks such

as interprofessional communication, reimbursement, discharge planning, and progress

monitoring. In recent studies, paper charting has shown to be “labor intensive” for medical

professionals to navigate due to the abundance of “redundant data, blank spaces, unclear writing,

and use of inappropriate abbreviations” (Akhu‐Zaheya et al., 2017, p. 582). Lack of pertinent
EFFECTS OF EHR AND USE OF THE MAR ON PATIENT CARE 4

information can lead to medical errors, compromising patient safety. In contrast, EHR

documentation has been proven to be “quicker, more legible and easier to share” than paper

charting (Martin et al., 2018, p. 3176). As a result, EHRs have been implemented in hospitals

nationwide in efforts to enhance the quality of documentation. In order to assess the

effectiveness of EHR documentation, researchers focused on the “clarity, ease of use and use of

abbreviations” (Akhu‐Zaheya et al., 2017, p. 579). Using these standards, research has shown

that in hospitals utilizing EHRs, “clinical care and research efforts are made more efficient and

perhaps include fewer errors” compared to hospitals utilizing paper charting (Martin et al., 2018,

p. 3176). Although continued research is necessary, studies suggest that the use of EHRs over

paper charting can improve nursing care and reduce the risk of error.

Documentation Quantity

As aforementioned, nursing documentation is an essential component of hospital

healthcare; however, due to nursing shortages and understaffing, consistent documentation can

often become tedious and overwhelming. Although EHRs do not eliminate the task of

documentation, studies show that they require less time and are more efficient than paper

charting, improving both the quantity and consistency of nursing documentation. Furthermore,

EHR flowsheets have the ability to prompt additional documentation relevant to information

already documented by the nurse. Consequently, “nurses using EHR documented more

information than those using paper charts, including the reason for PRN administration, who

initiated the administration, and effectiveness” (Martin et al., 2018, p. 3171). Studies show that

the ease of EHRs may have resulted in nursing documentation “[including] more information”

compared to paper charting (Martin et al., 2018, p. 3175). The increased quantity of nursing
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documentation facilitated by EHRs can aid in interdisciplinary communication, improve patient

outcomes, and decrease the possibility of medical errors.

Interprofessional Collaboration

When looking at quality of care for patients, interprofessional collaboration is important

to take into consideration. Interprofessional collaboration in healthcare is when different

professions share information regarding a patient as they work together to achieve a common

goal. A 2020 qualitative study looks at healthcare professional’s personal experiences regarding

interprofessional collaboration and the effect the EHR has on providing quality collaboration

between professionals (Mertens et al., 2020). The study focus is on interprofessional

collaboration in palliative care, so the sample used in the study is a palliative care network that

includes the settings of a hospital, the hospital’s palliative care unit and a nursing home. From

the network 9 group discussions were conducted and studied, with 53 diverse professionals from

different care settings. According to the study, “The electronic health record provides promising

opportunities to exchange patient information across settings and improve care coordination.

However, it requires changes and further development by the user and by technology” (Mertens

et al., 2020). The importance is that there is evidence that the ability of professionals to

collaborate through the EHR improves quality of care for patients, but that much greater

developments can be made in the future. The problem with interprofessional collaboration via

the EHR is that the best way for the different professionals to provide the best care for the patient

as a team is through collaboration meetings where attendance and communication are important.

This can be an issue when trying to communicate through technology. The study was organized

and provided good information backing up the point that EHR helps with care collaboration and
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continuity of care but that there are a lot of developments that still need to be made to really

improve patient care.

Patient Safety

When it comes to evaluating the effectiveness of an electronic health record, patient

safety is a good indicator of EHR success. Improving patient safety through electronic

documentation is a priority, and it is used to track and monitor adverse patient outcomes such as

infection, pulmonary embolism, and deep vein thrombosis. Research shows that the

improvement of patient safety is supported through the use of electronic health records. A study

by Walker-Czyz in 2016, showed evidence of a greater rate of reduction in catheter associated

urinary tract infections, in relation to using an electronic health record. The same study showed a

significant decrease in central line associated bloodstream infections (McCarthy, 2018, p. 3). The

aspects of electronic nursing documentation that improve patient safety the most include

accuracy, completeness, and decreased documentation errors. It is important to note that

although these interventions improve patient safety, it cannot be assured that nurses will comply

with documentation requirements. Patient safety and quality of care is specifically a priority in

acute hospital settings. Research shows that electronic nursing documentation has the potential to

contribute to these priorities if it is accurate, clear, and accessible. Evidence shows that shifting

from paper documentation to electronic is time saving and can help nurses improve efficiency

(McCarthy, 2018, p. 4). Through improved efficiency, the nurse will have more time for clinical

care and improving patient safety. Besides improving quality of care, patient safety is the key

point of improvement through electronic nursing documentation. The use of electronic nursing

documentation improved patient safety by providing some essential data entries and allergy

alerts that contributed to reducing medication errors (McCarthy, 2018, p. 6). A thorough
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electronic health record can provide nurses with the best decision-making process which should

improve patient safety.

Pressure Ulcer Documentation

When exploring the effects of electronic nursing documentation on the overall condition

of the patient in relation to adverse effects acquired in the hospital, the documentation of

pressure ulcers is a common highpoint of care. This is because pressure ulcer assessment and

documentation require a lot of attention and accuracy. Many hospital-acquired complications are

preventable. Through the use of electronic health records, the overall quality of health care has

changed dramatically. Pressure ulcers can be reduced through proper documentation of size,

characteristics and staging. Overall, electronic nursing documentation has been shown to

decrease pressure ulcers through the identification of high-risk patients (Li, 2016, p. 3). Patients

with a high risk of developing a pressure ulcer are highlighted on electronic health records

because the cost of managing them is not light. One of the biggest changes the electronic health

record makes to helping manage with pressure ulcers is the documentation of wounds through

pictures (Li, 2016, p. 6). Photographing pressure ulcers could help assist health care providers to

evaluate care on a day-to-day basis. More pictures and documentation in an electronic health

record proved to be a more accurate assessment than paper documentation. Documentation of

pressure ulcers in an electronic health record can prompt nurses to document more information

through reminders on the electronic health record. Through increased awareness, the electronic

health record was shown to improve descriptions on location, dressing type, granulation, wound

odor, wound color, drainage, physician notified, medication applied, and outcome description

(Li, 2016, p. 19).

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Accurate documentation is essential to account for the treatment and care of the patient

and interpersonal communication between the nurse and patient; furthermore, meticulous

charting can help to recognize new obstacles to healthcare and correct them accordingly. More

specifically, documentation of pressure ulcers can be drastically “improved [in areas such as]

pressure ulcer grade, size, and risk assessment, as well as nursing diagnoses, goals, and

interventions” (Gunningberg et al., 2009, p. 727). Additionally, correct documentation of

staging, size, tunneling etc. will inherently reduce risk factors and increase identification in

patients. Use of EHR also allows for more organized, time efficient charting seeing as EHR

permits quick, up to date, complete patient information. Medical documentation programs also

precipitate supplemental charting on account of “standardized preformulated templates that

ensure complete documentation at the point-of-care” (Gunningberg et al. 2009, p. 690). The

improved quality of documentation of pressure ulcers is largely due to EHR providing a more

standardized, comprehensive system of documentation.

Detection of Medication Errors

Proper medication administration and detection of errors are necessary to ensure the

safest, most effective medical care. Quality patient care is essential to a patient's health and well-

being. Research findings are suggestive that Medication Administration Errors (MAE) are lower

than previous recordings with the implementation of EHR and the use of barcode scanners for

the administration process. The barcodes are scanned during medication administration to verify

the patient’s identity and medications, resulting in a decreased number of MAEs. A MAE

occurrence is defined as any discrepancy between the providers orders and what was

administered to the patient. In a qualitative study aimed to detect errors, the rate of medication

error was monitored to compare the effectiveness of technology used with Bar Code Medication
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Administration (BCMA). Direct observation of the unit was utilized to collect data as it has been

found that this type of observation is more accurate and efficient in detecting MAEs than other

methods such as reviewing medical records or voluntary error reports. The purpose of this study

was to compare the rates of MAEs after the use of EHR in hospitals, and to identify possible

barriers to correct medication administration by nurses. In the same study, it was concluded that

“the frequency of medication errors was 5%” for the three units observed (Hardmeier et al.,

2014, p. 400). Out of the 300 observed medication administration, there were only 15 errors,

ranging from wrong medication to wrong route to wrong dose. It is also important to recognize

that technological advancements cannot prevent the occurrence of human error, meaning there is

no way to ensure 100% accuracy in medication administration by nurses. In addition, a portion

of the MAEs were a consequence of nursing staff not abiding by the rights to medication

administration. According to the study, “BCMA did not completely eliminate MAE”, but

relatively few BCMA workarounds were identified, making it easier to understand why and how

these errors occur and effectively teach how to prevent said incidence (Hardmeier et al., 2014, p.

367). Overall, research suggests that use of EHR and BCMA create more organized, easier to

share, up to date documentation that resulted in fewer errors than paper charting.

When it comes to the EHR within the intensive care unit (ICU), the rate of medical error

by use of the MAR has decreased since implementation, as studied over a two-year period in the

ICU of a hospital. When looking at these errors there was a study done before the

implementation of the MAR referred to as period one, and there were multiple studies done over

a two-year period afterwards. The results of this study show that the “The most common origin

of errors during period I was prescribing errors (44%), which significantly decreased in all post-

EHR implementation study periods (39.1%, 18.5%, 18.5%, p<0.001)” (Liao,et al. 2020). This
EFFECTS OF EHR AND USE OF THE MAR ON PATIENT CARE 10

showed that the number of times that a patient would receive a medication that was

contraindicated for their condition or interacted with another medication decreased significantly.

However, when it comes to other medical errors with medications, they showed that errors

actually increased. In fact, “40% of all errors that reached a patient occurred during the

administration stage” (Liao, et al. 2020.) These errors were a lot less harmful such as

medications given an hour before or an hour after their scheduled time. There were also errors

that were out of the nurses’ hands such as the medication not being available when it needed to

be given to the patient. Although all percentages of error did not decrease over the course of two

years the amount of harmful medical error when the EHR was in use continuously decreased.

Multiple Chronic Conditions

Research suggests that the use of electronic health records improves the quality of care

for patients with multiple chronic conditions. To best manage their conditions, patients with

multiple chronic conditions require interprofessional care and need to be provided with

continuity of care and follow-up appointments. A qualitative study about using the EHR to

measure quality of care for these patients was reviewed. According to Bayliss et al. (2016), there

is some EHR data that reflects quality of care in patients with multiple chronic medical

conditions has improved due to technology, and as technology advances the EHR can play a very

important role in optimizing care for these patients. The purpose of the study was to inform of

the increase in quality of care for patients with multiple chronic conditions with the use of the

EHR. The focus group included 10 individuals aged 70–87 with three to six chronic conditions

selected from a random sample of individuals aged 65 and older with three or more chronic

medical conditions. Webinars and the focus group were used for the experts to gain input on

what high-quality care looks like for a patient with multiple chronic conditions. The experts then
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used this input to decide what important components of care are and how the EHR measures

these components with prompted assessments. Using the Delphi method experts rated the

importance of each possible measure of care and the documentation of each measure using EHR

data. They correlated important components of care and the assessments in the EHR linked to

these important components. It was decided for each important component of care if the EHR

has successfully helped improve care relating to that component or if more technological

development was still needed. When first analyzing the study done by Bayliss, et al., it looked

lengthy and was hard to follow. However, tables inserted into the journal listing the domains of

important components of care along with examples of the documentation in the EHR are helpful

visuals for the audience to understand the study.

Continuity of Health Care

Focusing more directly on the EHR, the new technology improved the continuity, quality,

and cost of healthcare especially in communities with multiple health disparities. This is

especially important because of how much these communities utilize the hospital system.

“Since the most vulnerable, e.g., uninsured, low-income, racial/ethnic minority groups

are still more likely to visit a hospital emergency department for unnecessary care, there

is opportunity for hospitals to leverage their investments in technology to shift costly,

inappropriate utilization and reduce the detrimental impacts on health of socioeconomic

disparities.” (Viola, et al., 2017 p. 62)

The investment of technology within the hospital emergency department as well as

outpatient clinics help patients to spend less time in the hospital and spend less money in turn as

well. The opportunities that the EHR created allows for continuity of healthcare by providing

information on the patient's history as soon as they walk in the door at the emergency department
EFFECTS OF EHR AND USE OF THE MAR ON PATIENT CARE 12

(ED), allowing medical professionals to get them in and out without the need for a lengthy

hospital stay. More specifically, “the average cost of an ED visit is about $900 dollars. The

average cost of a hospital stay is ten times that amount” (Viola, et al., 2017 p. 62). The EHR

saves that money and time by providing a flawless continuum of care from outpatient clinics to

the hospitals or from previous hospital visits to the current one saving both the patients and the

hospital time and money. The EHR also has a feature adapted to care more specifically for

patients with health disparities by a risk factor system based upon the patient's zip code. This

means that within the hospital setting medical personnel can have a better understanding of the

socioeconomic background of that patient and risk factors that they now know to assess based on

their area. When this technology was implemented at the University of Arkansas Medical

Center, “they were able to reduce readmission rates by nearly 4%” (Viola, et al., 2017 p. 65) This

study is important to prove the technological advances benefit the patient’s quality of care and

decrease their trips to the hospital. The EHR not only carries information over from visit to visit

but contains models to help detect risk factors that allow for important teaching points to prevent

chronic illnesses. “The use of “Facebook” technology means we can learn not only about

someone’s shopping preferences but whether they are predisposed to a readmission, heart

failure, or a missed appointment.” (Viola et al. pg 66) When looking at a patient, health care

providers now have the opportunity to teach about ways to avoid developing conditions that

otherwise would go unnoticed if it wasn’t for the EHR. The EHR helps to lower rates of

readmission, lower costs, lower lengths of stay, and help to prevent chronic disease by

identifying risk factors and socioeconomic disparities.

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Conclusion

In conclusion, the implementation of the EHR and MAR has affected healthcare in many

different positive ways. The use of the EHR enhances the ability of healthcare workers to

promote the continuum of care, reduces the risk for readmission, reduces the development of

chronic illnesses because of identified risk factors, and lowers costs of healthcare. The MAR

when implemented also reduced the amounts of harmful medical errors.

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