Citation: Ozduyan Kilic, M. & Korkmaz, F. (2023). Nursing care related data in Turkish electronic health record systems: A literature review. Online Journal of Nursing Informatics (OJNI), 26(3). https://www.himss.org/resources/online-journal-nursing-informatics
Aim: Electronic health record systems are used widely to record data on people's past, present, and future health conditions. Like other healthcare professionals, nurses commonly use electronic health record systems and manage sizeable health-related data sets. Therefore, this review focused on to what extend nurses in Turkey use electronic health record systems/hospital information systems and which data is recorded.
Methods: This study is a traditional/narrative literature review. The authors searched five databases (Medline Complete, ScienceDirect, Web of Science, Google Scholar, and Ulakbim National Database). Articles about nursing data recorded in electronic health record systems/hospital information systems, written in English or Turkish, took place from 2008 to 2022 in Turkey were included.
Results: Ten articles were examined; the authors analyzed articles under two headings according to their results, 'medical treatment related nursing data' and 'nursing care related data.' The results showed that medical treatment related nursing data was documented more frequently electronically, whereas nursing care related data was often kept in hard copy.
Conclusion: All medical treatments related to nursing data (data employed or recorded by nurses) are documented electronically. However, to a great extent, nursing care related data are still either communicated verbally or recorded on paper forms. Hence, nursing care related data needs to be gradually transferred to electronic systems for the sake of high-quality, safe, and continuous care.
Key Words: Documentation, electronic health record system; hospital information management system, nursing.
The electronic health record (EHR) is defined as a digital record of a patient's past, present, and future health conditions that are accessed, stored, transmitted, exchanged, and evaluated as a result of the information generated for patient care from the patient's health care visits within or across health care organizations (Kelley, 2016). To manage healthcare services, countries have started to transfer patient-related data to electronic health record systems (EHRS) since the 1970s (TMoH, 1997). Turkey as a nation began to set up and install the hospital information management systems (HIMS) for all public hospitals by 2008 (Turkish Ministry of Health, 2008). Because the software programs for HIMS used in the country are developed by different organizations/companies, there is no standard software available uniformly (Göktaş et al., 2017) Nevertheless, legal regulations have been introduced to integrate medical (laboratory, pharmacy, inpatient, outpatient, radiology, nursing, etc.) and administrative (invoicing, personnel operations, archive, etc.) modules into HIMS software programs (Turkish Ministry of Health, 2018). Managers mainly used those modules mentioned above to monitor the financial/administrative services, where physicians and nurses monitor healthcare delivery (medical treatment-related and care-related services).
Nurses use EHRS/HIMS regularly because they are responsible for both nursing care and medical treatments. Therefore, software systems developed for hospitals always included a nursing module. Research about nursing modules shows that EHRS/HIMs help manage adverse events that patients may experience (pressure ulcers, patient falls, medication errors, etc.), increase time devoted to patient care, and help the profession improve the quality of documentation (Ahn & Park, 2013; Callen et al., 2013; Dowding, et al., 2012; Fieler, et al., 2013; Karp, et al., 2019; McComas, et al., 2014). These results indicate that to increase nursing care quality, the data collected, monitored, managed, and shared by nurses while delivering care independently or collaborating with other healthcare professionals should be identified/ observed on EHRS/HIMS to strengthen the care activities.
Compliance of EHR/HIM Data with International Standards
In 2008, HIMS were installed in all health institutions in Turkey, allowing healthcare professionals to access and monitor electronic health data. In 2013, the data was aligned with international standards. To that end, the Ministry of Health (MoH) held talks with the Healthcare Information and Management Systems Society (HIMSS), which then evaluated the health institutions' electronic medical records in line with internationally accepted criteria (Electronic Medical Record Adoption Model [EMRAM]) (Zehir, 2018). HIMMS scores electronic health records on a scale of 0 to 7 (Stage 0: the three critical ancillary department systems: laboratory, pharmacy, and radiology, are not installed; Stage 7: all medical data, medical images, and other documents [protocols, paper charts, etc.] can be monitored digitally) (HIMSS, 2019). According to HIMMS evaluation, there are a few hospitals in Turkey with a Stage 6 (55 hospitals) and a Stage 7 (7 hospitals) accreditation (about 16 percent of Turkish Ministry of Health hospitals (Turkish Ministry of Health Digital Hospital, 2023). As can be understood from EHRS/HIMS data compliance with international standards, hospitals maintain varying EHRS/HIMS levels, thus nursing documentation differs accordingly in Turkey. This review focused on for what purpose nurses in Turkey use EHRS/HIMS and to what extent do nurses record data.
This study is a traditional/narrative literature review. The framework for carrying out a formal literature review, as suggested by Li and Wang (2018) was followed for this review. The search was carried out on Medline Complete, ScienceDirect, Web of Science, Google Scholar, and National Database (Ulakbim). We searched databases with "electronic health record systems," "hospital information management systems," "nurses and computer use," "nurses and information systems" keywords. Articles about nursing care-related data on electronic health record systems/hospital information systems, written in English or Turkish, from 2008 to 2022 in Turkey were included. Ten articles were selected out of a potential relevant 49 articles within the initial 5431 article results. (Figure 1).
The authors each read the ten articles and classified the results. When the authors concluded different opinions on any subject, they discussed it and collaborated on the final conclusion. The authors analyzed articles under two headings, 'medical treatment-related nursing data' and 'nursing care-related data' according to completeness and accuracy.
The number of studies identified, screened, included, or excluded at each stage of study selection can be seen in Figure 1. Eventually, ten articles were included in the study. (Arikan, et al., 2022; Ay & Polat, 2014; Çakırlar & Mendi, 2016; Çelik, et al., 2017; Özdemir & Karakaya, 2017; Öztürk, et al., 2022; Tiryaki, et al., 2018; Top & Gider, 2012; Top, et al., 2013; Top et al., 2015).
The characteristics of the reviewed papers are presented in Table 1. Studies' sample size varies from 52 to 601 nurses (incl. nurses with management duty) (Table 1). The studies were conducted on a regional basis with no districts' study results. Most of them employed the quantitative method. The mixed method was used in two of the ten articles, and one of them consisted of survey generation. Most of the studies used self-reporting to analyze nurses' EHRS/HIMS/computer use in their working area. In one study, the authors used a semi-structured survey to determine the nurse managers' views and attitudes towards EHRS/HIMS. However, throughout these studies, there was minimal information related to data collected and monitored by nurses. According to the review results, the authors identified two headings and analyzed the data accordingly.
Medical treatment related to nursing data
Medical treatment-related nursing data is recorded due to the tasks nurses perform in collaboration with other health professionals, such as evaluation of medication administration, laboratory, and radiology results. As shown in Table 1, EHRS/HIMS modules were used by nurses to monitor treatment plans, request supplies from pharmacies, document medication administration, and evaluate laboratory results. Three of the reviewed studies showed that the laboratory module was used more frequently by nurses. In contrast, one of the papers indicated that it was the pharmacy module used more regularly. However, the use frequency of these two modules did not differ from each other. Based on study reviews, it can be said that medical treatment-related nursing data was the most available data electronically, and nurses used EHRS/HIMS primarily for monitoring these data while delivering care to patients.
Nursing care related data
Nursing care plans, daily nursing care notes, and patient care observations are included under this heading. According to the study results, the frequency of nurses using EHRS/HIMS or computers to record nursing care documentation is relatively low. One of the reviewed studies showed that most nurses did not use EHRS/HIMS to document nursing care plans/nurse care worksheets, enter daily nursing care notes, or capture patient observations. However, in one study, a semi-structured interview, nurses stated that they use computers in the workplace to document nursing care-related data (such as documenting vital signs, taking printouts of the nursing care process, and patient discharge education). The differing results in these studies may result from the methodological differences of reviewed articles. However, it can be seen that this data is being identified and transferred to electronic systems at an increasing rate.
The study results included in this review are limited: no study has been conducted to cover an examination of all nursing data on EHRS across the country. It is difficult to determine which nursing data are recorded on EHRS/HIMS and which are still recorded as hard copy only. Therefore, the authors created Table 2 due to a two-month study based on their education, clinical experience, and observations (regarding hospitals with diverse levels of EHRS/HIMS) to explain how the data collected by nurses transferred to these systems. While producing the table, the authors grouped the data under two headings in line with the review results. Then they detailed the nursing care-related data under each system separately. They discussed how each data was recorded/transmitted throughout the healthcare team and agreed on the ultimate version of the table. Table 2 provides a comprehensive description of how nursing data is documented (differences in documentation according to the hospitals) and what nurses do independently or collaborate with others in the care environment.
This study focused on the purpose of EHRS/HIMS use and found out which data is recorded and to what extent by nurses in Turkey. We have found that all medical treatment related nursing data (data employed or recorded by nurses) is monitored electronically. However, to a great extent, nursing care-related data is still communicated verbally or recorded on paper forms in Turkey. Traceability of medical records is necessary for patient care and the Social Security Institution to reimburse health institutions for patient services. Therefore, hospital administration are currently placing a particular emphasis on monitoring and keeping these records.
Moreover, the Turkish Health Authority mandates all medical institutions to use standards (Picture Archiving and Communication Systems, etc.) developed for EHRS/HIMS software programs and instructs them about using these standards to monitor the medical records. Because medical treatment-related data are available in electronic medical records and EHRS/HIMS modules, this allows nurses to monitor treatment plans, request supplies from pharmacies, record medication administration, and evaluate lab test results (Ay & Polat, 2014; Çakırlar & Mendi, 2016; Çelik et al., 2017; Özdemir & Karakaya, 2017; Top & Gider, 2012; Top et al., 2015). But there is no standard available to set the rules for recording nurses' data and transferring it to EHRS/HIMS.
Nursing care-related data are essential for nurses and other health care professionals to provide adequate health service to patients. Therefore, it is crucial to determine how this data is recorded. We have found that there are no defined standards for recording nursing care-related data in Turkey and that nurses convey most of their data verbally. At the same time, a portion of this data is documented on printed forms (Table 2). Additionally, our results indicated that nurses' frequency of electronic health record systems to record nursing care-related data remained relatively low (Table 1). However, evidence from literature suggested that using electronic systems instead of hard copy documentation improves patient outcomes (e.g., reduced mortality/pressure ulcer occurrence, etc.) and reduces errors, especially in vital signs documentation (Ahn & Park, 2013; Callen et al., 2013; Dowding et al., 2012; Fieler et al., 2013).
However, in contrast to our results, some study results showed that nursing-related documentation quality in the electronic system was not superior to hard-copy recording (Akhu-Zaheya, et al., 2018; Wang, Yu, & Hailey, 2015). In Turkey, nursing is still struggling with many challenges associated with a lack of adequate development, making it hard to define each nursing intervention applicable across the country in a standardized way. Moreover, there is no generally accepted translation of standard nursing terminologies that could define proper interventions. Hence, each hospital is adopting its own classification/terminology, and most of them prefer to just omitting the data and let nurses share their data verbally. In 2008, health authorities launched specific regulations on using nursing processes and recording the managed care plan either on paper or on the computer, based on the hospitals starting to pay attention to the elements that should be included in EHRS/HIMS in terms of its nursing module.
Healthcare-related data is being transferred to electronic systems and harmonized with international standards throughout the country. Meanwhile, nursing care-related data have also begun to be identified and assigned to electronic systems at an increasing rate. All medical care-related data used or recorded by nurses are monitored electronically. However, to a great extent, nursing care-related data managed by nurses is either communicated verbally or recorded on paper forms. Therefore, it has become evident that nursing care-related data need to be urgently transferred to electronic systems step by step for high-quality, safe, and continuous care. Based on all this content, nurses in Turkey could work with their hospital or health system committees and nursing organizations to make nursing content become part of EHRS. It could be possible to create a minimum data set to serve as nursing content for EHRS. Furthermore, handwritten documents such as the nursing care plans could be automated as much as possible. Thus, nurses would determine the necessary documentation to support safe patient care, optimal outcomes, and compliance with professional nursing standards.
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Bachelor of Nursing from Gulhane Military Medical Academy School of Nursing
Bachelor of Classical Archeology from Ankara University, Faculty of Language, History and Geography
Masters in Nursing Management from Hacettepe University Institute of Health Sciences
PhD in Nursing student at Hacettepe University Institute of Health Sciences
Lecturer, Ankara University, Faculty of Nursing, Ankara, Turkey.
Associate Professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey
Bachelor’s, Master’s and PhD all completed at Hacettepe University, Ankara, Turkey