Electronic medical records and patients privacy
Today most of the healthcare organization all over the world are implementing electronic healthcare medical record systems. Even though with the emerging technologies, there is a need to upgrade to these systems, there are many complexities which need to be understood in these systems.
It is very important to understand healthcare information system which is currently in use and what is the necessity of changing it to an electronic medical record system before even deciding to implement the same. To understand the basic things, a medical record which can be electronic or paper based is one such communication tool which supports coordination of services. Along with this, it is also helpful for clinical decision making, evaluating efficacy as well as the quality of the services given, for legal protection, research, accreditation, education, and even for regulatory processes.
The medical record is the business record in case of the health care system. The medical record is documented even in normal care in medical activities. It must be authenticated, and in case if it is written in hand, all the entries made should be legible. In the past, even today, in some healthcare organizations, medical records are recorded as a paper repository. They are reviewed and even used for research, clinical, financial, and even for administrative purposes.
When the record is in the paper, it is highly limited in terms of availability, accessibility to a single user. These paper-based records should get updated manually, and hence, there will be delays in completion of the records. In some cases, there can be a delay of 6 months or even more. Along with this, since there will be a need for too much space for these records, healthcare organizations place them in the basements. The physicians must take responsibility of caring as well as documenting these processes. This is the reason most of the patients were unable to view their information.
There is one more limitation for this medical record system, which is paper-based. That is lack of security. So, even though there is control on access, it is controlled just by locks, doors, identification cards, and sign out tedious procedures. There is no such alert system which can indicate unauthorized access to the patient information, and there is no clue on what information has been viewed by the unauthorized users. But there was less chance of stealing the paper record but with the implementation of EMR, in case if a person steals login information, there is a chance that he may access information which is not related to him.
EMR and its role in healthcare organizations
The main purpose of implementing EMR documentation remains the same that is patient care. But the same clinical documentation will be scanned into some electronic system, and this is done immediately. They make sure that this is done even before the patient gets discharged. There will be regulatory and accrediting requirements on record completion. The best thing about an electronic health record system is it is interactive. One more thing is there will be many users, reviewers, and stakeholders for this documentation.
It is possible to view this electronic medical record by many users at the same time. It just requires a host of tools which belong to information technology. It is possible for the patients to review their records regularly, and it becomes easy to keep track of their health records which come with all the necessary clinical documentation. This documentation may contain information about their complete diagnoses, healthcare websites, and information about their physician as well. So, now patients also can access their health records with patient logins, patients should be made aware of the danger of sharing access to the login.
The owner of this electronic medical record will be healthcare practice or organization, or the physician. This is because it is the business record or business property for a healthcare organization. Of course, the information in the record is always owned by the patient. Even though the actual record belongs to the doctor or the facility, the information always belongs to the patient. This is the reason security, privacy, and confidentiality, and availability and data integrity are the three main ethical priorities which must be considered by an electronic medical record system. Hacking is one other thing that can happen if the EMR is compromised, so the practices must select a proper well secured EMR.
It is very important that before releasing patient information, they must always take patient’s consent. But this doesn’t mean that physician should not gain access to the patient information. The information can be used when necessary for the payment, treatment, and even for the administrative purposes. The patient has state, federal, and legal right for viewing, getting a copy, and to amend some information present in his record.
Staff handling the records should be made aware of the ethical priorities. Today there is a high need for work ethics training, and monitoring also has become essential for all practices to avoid misuse of information.
There is a key to preserve the confidentiality of the patient information, and that is done by giving access only to authorized individuals. So, there must be a process to limit the control of access, and that should begin with authorizing the users. There should be usernames and passwords, and those should be assigned based on the level of information which is needed by that individual user. There must be a 2-tier approach when it comes to authentication. It is a better idea to add biometric identifier scan, finger, palm, face recognition, or even retina. Today, HIPAA agreements matter even more since the possibilities of the breach have increased multifold.
Along with these there are many other concerns as well since electronic data even though deleted can be recovered by software designed for that purpose, so even after deletion of data, the security of the data is at risk. So if there is a hardware problem, care must be taken when giving the computer or hard drives for repair, it is better to have someone come in-house to do it. Other than these, measures must be taken so that all faulty hardware which does not have any scope of repair has to be destroyed completely such that the data is also destroyed.
There is always increasing concern when it comes to health information, especially with the implementation of electronic medical records. There is high concern about the security because earlier with paper records, files had very limited access only to doctors and practice staff. But when they implemented electronic medical records, they can be accessed by anyone with log in access to the system.