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Electronic Health Records Essay Paper

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Electronic Health Records

Introduction

As a nurse, one comes into contact continually with issues of electronic health records. The Health Insurance Portability and Accountability Act is one of the Acts of the Federal Government that attempt to speak to the question of electronic health records. In this case, it is required that in the provision of cover for Americans, there is need to have a catalog of information kept by the health care providers which can be used in the offer of health covers (Hiller et al, 2011).

The HIPPA provides for mechanisms of protection of such information by the privacy rule which demands that Personally Identifiable information ought not to be disclosed unless within the framework provided for under the Act (Bates, 2005).

Background

It is the case that such information may be used in the carrying out of research. However, there is no clear methodology of addressing intellectual property concerns in the information that is stored therein. Most certainly, the IP in the coming up with software that can store such information is squarely an entitlement of the software developer.

Where does this leave the information and the collector of information? This is a question that must be determined to inform agreements that organizations which offer IT services to the health care providers may have to craft in their Service Level Agreements. (Garde, 2007)

It cannot be avoided that this is an issue that deserves adequate attention because often, the patient will not know whether they have any rights regarding the information they give herein. This actually gives them impetus to lie about the information they give.

Even if they do not lie about the information they give, they may end up being a bit economical about the truth in the information they give. The growing need for enhancement and embrace technology in every area and the growing relevance of cloud storage means that the traditional ways of record keeping by health care providers is an idea of a bygone age. (Garde, 2007).

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It is a mundane principle of IP law that information gathering cannot amount to a situation where the gatherer is granted IP rights. This is because IP rights involve the exertion of mental capacities and the sweat of the brow cannot suffice for the abrogation of such rights by one such person. Ultimately, there is then a question that arises. Who then is entitled to such rights?

These information rights will inform how we handle such information and the procedures to be followed in the use or transfer of such information. The seriousness of the question of confidentiality and security of information is at the centre of electronic health records. In the event that this is not properly addressed, there is a real possibility that the policy on the creation of such records crumbles and the efficiency envisioned in such an instance fails in the main.

Findings

A priority, I perceive need to have a brief legislation on the IP rights regarding such scenarios. In such a case, there is need to properly brainstorm and see whether a law can be crafted to even sanction properly the actions of such persons who may handle such information, for instance nurses as they go about with their ordinary dealings.

It may then appear as though there shall be an overlap with the question of Confidentiality as already provided for in other pieces of legislation including HIPAA. However, this will be more specific and will spell out clearly the IP rights and offer a more comfortable pillow for the patient and users of such information will be under a more elaborate set of duties. (Zittrain, 2000)

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Procedure

There is an elaborate procedure for the making of laws. In this my case, I have already encountered the need by observation and from experience that there is no clear policy directive on such. There is also an alarming dearth of scholarly attention to such an area which has far reaching implications for research. A focus group discussion with members of the profession reveals that information may be abused without the knowledge of the proper owners of the said property which is actually a virtual violation of the fundamental right to dignity.

It is the case that information that is de-identified may be used for research with few qualms. However, this does not completely take away the need to have the proper owners of the information at the centre of such a procedure.

This procedure is made easier by the fact that a citizen like me may institute the procedure without being found to have lacked the requisite locus. As the law progresses, the question of locus is slowly being found to be merely procedural and cannot be allowed to supersede substantive societal needs and justice. As a matter of conjecture, this will need a bit of education of the stakeholders on the issues to which this law will speak to.

Only then will a critical mass be achieved because this is a fairly technical area that may not be fully appreciated by many. However, IP Law is an issue of concern to all policy makers because the traditional forms of property are slowly being phased out.

The presentation of such laws to both houses of congress, both of whom must ruminate over the proposals and determine whether or not they deserve parliamentary attention. (Mason, 2015) It is hoped that the idea shall not die at the committee stage, but shall sail through to help protect the rights of patients.

References

Bates, D., 2005. Physicians and ambulatory electronic health records.”. Health Affairs, 24(5), pp. 1180-1189..

Garde, S., 2007. “Towards Semantic Interoperability for Electronic Health Records–Domain Knowledge Governance for open EHR Archetypes.”. Methods of information in medicine, 36(3), pp. 332-343..

Hiller, J., McMullen, M. S., Chumney, W. M., & Baumer, D. L. (2011). Privacy and security in the implementation of health information technology (electronic health records): US and EU compared. BUJ Sci. & Tech. L., 17, 1.

Mason, A. T. a. G. S., 2015. . American constitutional law: introductory essays and selected cases.. 1 ed. New York: Routledge.

Zittrain, J., 2000. “What the publisher can teach the patient: intellectual property and privacy in an era of trusted privication.. Stanford Law Review, pp. 1201-1250.

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System Downtime

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System Downtime

According to LaTour & Maki (2010) downtime is a period of time when there is a failure of the system to perform or provide its primary function. Downtime may either be planned or unplanned during which the proper functioning of the system is compromised or it is unavailable to user, and this is often caused by either environmental factors, computer system failure, network failure, software failure, interface failure, and/or routine scheduled upgrades or maintenance.

According to the staff working at the hospital i.e. KKUH, downtime occurrence with regards to HIMS does not take place often at the hospital. For example, the last time a downtime was experienced at the hospital was two months ago and it only lasted for about a half an hour at the emergency department only. The eSIHI was implemented recently meaning it is still new for all staff at KKUH.

On the other hand, apart from unplanned downtime it is possible for a downtime to be planned or scheduled, that is, a period during which through a deliberate or intentional alterations or modifications the health information system is unavailable to users or is not able to function properly. During planned downtime, the system may not be affected as a whole or in totality, meaning some functions may still perform properly or the system may still be available to some users. The purpose of planned or scheduled downtime is mainly scheduled maintenance, system upgrades and updates.

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During a down-time whether unplanned or planned, the admission procedures at the Emergency Department changes to ensure health care services continue. At the Ambulatory and Emergency Department, during a period of downtime the officer responsible for all kinds of documentation is the physician in-charge and ensures instant scanning of the documents.

Unit clerk/nurse is responsible of providing all necessary forms during downtime, and ensures that the scanned instantly and uploading of the documents is done when the system recovers. Down Time Support Team has the responsibility of uploading documents that were scanned during a downtime and entering of orders in eSIHI upon the recovery of the system, usually before that day ends.

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Admission officers at the Emergency Department should be aware of the appropriate procedures during a downtime because the office of Admission is responsible of registration of all patients for admission (Moore & Fisher, 2012). The standard admission procedures are as follows:

For new admissions, during a down-time a manual ADMISSION face sheet is completed by admission officers for each admitted patient.
The patient is then sent to the appropriate unit for further emergency care because Emergency Department cannot offer such care for long especially when it is intensive.
The patient is accompanied by the following documents: 1) the manual ADMISSION face sheet; 2) patient labels as well as armbands; 3) patient admission orders (when they are available).
In the absence of the patient admitting orders, the Nurse or any other designated person who is appropriate calls the Admitting orders from the admitting physician.
If the Admission orders arise from the nursing unit, especially in case of a newborn the Admission desk is called by the nursing unit for their notification about the new admission.
The Admission unit clerks/officers/designee uses a downtime packet to establish a patient’s chart, and each page must be labeled with the name of the patient, FIN NUMBERS or medical record number, room and bed of the admitted patient as well as the name of the admitting physician.
Discharges should be limited as much as possible during downtime due to the increased potential for errors, but when necessary to discharge the Admission desk is called by the discharging unit for their notification about the discharge. The manual discharging documents during downtime are added to the chart of the patient and maintained on the nursing unit where the patient was admitted until the system recovers when the documents are uploaded.

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Documentation by Admission officers during a downtime should ensure that: 1) all forms filled during downtime are labeled accordingly using two identifiers for the patient (at minimum the date of birth and name); 2) the downtime forms are always required to have a date, time, and signature; 3) on top of each medication order, the nurse must indicate “Allergy”; 4) the filling of all paper forms is done as part of the medical record for the patient.

References

LaTour, K. M., & Maki, S. E. (2010). Health information management concepts, principles, and practice. Chicago, Illinois: American Health Information Management Association.

Moore, A., & Fisher, K. (2012). Healthcare Information Technology and Medical-Surgical Nurse: The Emergence of a New Care Partnership. CIN: Computers, Informatics, Nursing, 30(3), 157-163.

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Patient Master Index Essay Paper

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Patient Master Index

The Patient Master Index/Master Patient Index/Central Patient Index is a database that holds information of all patients with the hospital. The main purpose of Patient Master Index is to enable creation of UMRN and ensuring each patient is assigned to one UMRN. The creation of data into the PMI and update is authorized to relevant documentation clerks, laboratory clerks, and emergency clerks (Perera et al., 2011).

Creation of a health record file entails the details of employment clinic, eligibility office, and emergency department. The mandatory data about a patient that must be recorded includes their surname, date of birth, given names, address, and national identification number (Chaudhry et al., 2006).

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Through the CPI and A&E, patient demographics can be verified and updated because both can be used in the creation of patient medical records number, however the CPI is the only one able to update demographic details of a patient, while A&E can be used to verify. The identification and management of potential errors is achieved through the UMRN Inactivation/Merged in Error.

For instance, when there is merge/inactivation of an incorrect record, site specific procedures are implemented to deal with the occurrence. Consequently, all systems utilizing eSIHI data through interfaces will forthwith hold the incorrect data against the correct UMRN, and a script then shows the inactivated UMRN to the newly retrieved patient’s correct UMRN registration. The supervisor is then notified for subsequent approval.

Reference

Chaudhry, B., Wang, J., & Wu, S. et al., (2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine, 144(10), 742–752.

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Patient Administration System Essay

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Patient Administration System

Question 27

Upon the implementation of KKUH’s Patient Administration System (eSIHI) in May 2015, it was subsequently integrated with King Abdulaziz University Hospital (KAUH). This means that if a medical file number of a patient exists at KKUH, the patient also has a file number at KAUH. Yes, there is a global UMRN because eSIHI interfaces with other systems such as Xcelera reports, Dictation (via fly), PACS (Radiology), 3M, employee Health Record as well as medical sick leave.

Apart from KKUH, a 950-bed capacity hospital which uses this UMRN, this UMRN is also used by KAUH a 200-bed capacity hospital. These two hospitals use a Patient Administration System (PAS) known as eSIHI, which is integrated between the two hospitals meaning that it is possible for the two hospitals to share records when necessary.

Question 28

The Patient Administration System (PAS) used by the King Khalid University Hospital (KKUH) is eSIHI, which was implemented in May the year 2005 and the hospital has no plans of replacing it even though any improvement plans may be considered. The hospital’s PAS, which is eSIHI is offered by the HIS company and will run on the software architecture of Cerner Millennium^®, which is a highly unified and comprehensive information management architecture.

Hospital reports are generated whenever required or periodically for monitoring purposes. The existing system has various benefits, and hospitals adopting this system will recognize several imperative benefits, including:

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Increased quality of care for patients: This will be achieved through elimination of errors by electronic order entries, which were previously caused by improper transcriptions or illegible handwriting, while physicians are notified by evidence-based alerts of potential complications associated to similar situations and medication interactions.
Improved patient information access: The creation of electronic health record that is integrated for each patient, allows vital health information to be accessed in real-time, including updated radiology imagery and lab results.
Enhanced operational efficiency: As a result of the on-time reporting offered by this system, it enables hospitals to be able to have greater control over the day-to-day operations across all the departments, while at the same time increasing efficiency and reduction of costs.

However, compared to the old system that the hospital was using, the new system (eSIHI) has a major disadvantage, which according to the staff through the old system they were able to know whether a patient has died or not, but with the new system it is not possible for them to know.

In the new system, information flows from the patient to the health record department to physician consultations, then diagnosis (i.e. lab or radiology) to surgical/dressing/radiology departments, then pharmacy and finally the finance and discharge departments. The new system is easy to use compared to the old one, and the access of medical records or information is by scanning the barcode.

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Database Characteristics and the Language of Health Information

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Database Characteristics and the Language of Health Information

Introduction

Electronic information systems are a strategic idea that any organization can adopt. Information systems help organizations to store information in an organized format that can be easily retrieved. Using information systems in hospitals will guarantee the safety of information for both the patient and the provider by making it easy to store and access health care information.

This is a shift from the manual hard copy store of data to the digital store of information (Beaumont, 2000). This will enable the storage, retrieval and processing of health data easily. This data is stored on a database that keeps all the information according to the format that the administrator has assigned it. This overview is guided by the outlined questions that are highlighted.

The hospital is faced with the storage of records on paper copies and files. The patient records have to be searched through the numerous files within the hospital and its respective centres in order to access a record. Furthermore the hospital needs to have information from its centres linked to the main hospital for it to be easily accessed.

The aim of this project is to develop an electronic health information system that will capture all the information of the hospital and its centres n one database that is easy to access and reliable. This presentation gives an overview of the relevance of adopting a health management system. It highlights the relevance of shifting from the manual paper work to a digital model of record keeping.

Fundamentals of database characteristics and structure

A database is a collection of data that is related that can be produced to information that is relevant to the user. A database is large since it has to store a lot of information ranging from figure to word. Beaumont (2000) argues that data represents facts that are recorded and can be processed to produce information that is based on the facts that are stored in the database.

These data is maintained as a collection of files that are stored in a database management system. A database management system has several programs that enable the users to enter data into the system and processing it into information that is relevant to the end user.

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In changing the hospital system to an EHR a database will be developed where data is entered into the database for access by several users on different platforms. The database is self describing; it insulates programs and data, supports viewing of data from multiple sources and enables the sharing of data across several users.

The database will be easy t use since it has definition of its components like, storage format, individual files structure, and the data constrains that may exist. The database will have different users that are differentiated from the way they use the database. They can be programmers, sophisticated users, specialized users or native users.

All these users can access the database but their use is limited according to the administrator privileges that exist in the database (Versel, 2011). The administrator coordinates the whole database system and understands the needs of each user and the privileges that should be assigned to the user.

Types of medical data and information records relevant to this project

According to Szolovits (2003), Hospitals keep different types of data that is relevant to both the government and the healthcare facility. The information is used in government planning for specific cases of illness and also in determining the patient disease patterns. The database will contain patient records and health records

Patient medical records contain the identification of the patient like, name, sex, age, residence blood type, chronic diseases, family health history and previous prescriptions ever administered to the patient. This data is entered in a database that can be shared across hospitals in a digital format through a network connecting all hospitals.

This aids in ensuring that the medication given to the patient is consistent unlike the manual system where the patient may have to narrate the prescriptions given to them (Szolovits, 2003). Individual files for each patient are supposed to be kept that help in making diagnosis for future cases of illness. The records help the patient and the doctor to make a diagnosis that best fits the situation of the patient.

On the other hand health records give a summary of the healthcare services and patterns that have been registered in the facility. These records are classified using different indicators for example they can be according to the disease that has been diagnosed or can be based on the type of drugs that have been administered to patients. These records are used by planners and policy makers to make decisions that affect the healthcare system (Versel, 2011). The type of health information stored will depend on state requirements that have been set.

The records will be linked to the main server that is located in the main facility. Each facility will have a login ID that will be used to record the cases in that facility. This will ensure that the cases can be differentiated easily as having been registered in one centre or the other.

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The importance of uniform terminology, coding, and standardization of the data

Use of uniform terminology entails harmonising the health information systems that exist to use terms that are similar across. Since the health standards are equal and have been set by the WHO then it means the terminologies used should apply across the globe. The use of uniform terminologies enables the exchange of health information and data among systems in a uniform manner. Therefore the medical terms have to be understood universally (Ramez & Shamkant, 2003).

Coding enables the practitioners and the health information system to easily interpret the data using the health information that has been built in the system. Coding is computer assisted increases the efficiency of the codes so that the codes are not human generated universally (Ramez & Shamkant, 2003).

Coding is further used in clinical health surveillance and decisions support within the healthcare. Coding makes the interpretation of data easy thus increasing health surveillance and the application of health information universally (Ramez & Shamkant, 2003)..

On the other hand Ramez & Shamkant (2003) argue that universally standardization of data ensures a uniform platform that all practitioners work on. This improves quality and efficiency during health care. Standards are defined by several organizations like ISO that determine that ensure all practitioners use a standard platform in healthcare.

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Information standards and organizations that may be applicable, and possibly required, for this project

In the current world where quality is a prerequisite, there are standards that are required for every organization or application that is used. ISO TC 215 sets standards that are required for electronic health records. It provides international specifications that are required which are described in ISO 18308 (Szolovits, 2003).

However there are 55 countries that have subscribed to the global authority in health care information health seven international. Below are various standards that guide the use of electronic health records.

HL7- a texting protocol between the physician and record systems and practice management systems.

ASC X12(12), a protocol for transmitting data of patients, this is commonly used in the US.

Claims attachment standard; it guides the submissions and making of claims in a health care System.

Personal health records standard that ensures uniformity of patient health records across countries.

The healthcare information systems vendor that offers electronic medical record products

Acummedic health: it’s a practice management and EHR application that is customised to capture the health care flow from the contact with the patient to discharge. The advantage with this system is it gives the opportunity for the user to add modules that are relevant to their agency. It supports the HL7 standard and offers several packages like substance abuse, behavioural health, community service and many others. It has been in use since 1977 and offers better platforms for EHR (Versel, 2011).

Acumen Physician Solutions is designed for nephrologists; it offers physician guideline and ambulatory services and is wholly owned by Fresenius Medical Care North America. Therefore the services it offers are linked to Fresenius Medical Care North America (Versel, 2011).

BML MedRecords Alert LLC was designed to provide solutions that are more efficient and a better healthcare system. It provides physicians with a digital platform to interact and gather information from patients. It allows the patients to easily access their medical information from anywhere and can be effective during emergency. Further it has medical alerts that patients can use and an online library for referral. This leads to both quality and efficiency in achieving healthcare (McBride, 2012).

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From the three EHR vendors, it is noted that they vary in their application but offer interaction between the patient and the healthcare provider. However Acumen Physician Solutions offers ambulatory services apart from the services that all others offer, while BML MedRecords Alert LLC offers a patient profile that the patient can search through the website and get information that can be relevant for emergency.

The patient is able to easily access the health records and can interact directly with the physician without physical contact. While Acummedic health is an open platform that enables the user to change and add the modules that are relevant, this shows why it has been in use since 1977. Therefore all the EHR vendors are good and will depend on the user preferences and requirements. The cost of installing the system will range from a minimum of $3000 US dollars.

Conclusion

Electronic Health records system helps to coordinate and make healthcare provision easy and fast to patients. According to Grooves et al (2013), health facilities use the system to increase performance and efficiency of the healthcare system. It assists the health care providers to exchange and coordinate information from one source to another. The Electronic Health records system provider immediate access to health records and literature by practitioners that helps in diagnosing medical cases.

The sharing of information between the patient, the practitioner and other health facilities has improved the quality of care. This is the invention that has brought health care to the door step of the patient and further reduced the distance between the patient and the hospital.

References

Beaumont, R. (2000). Database and Database Management Systems. Retrieved August 12, 2009, from http://www.fhi.rcsed.ac.uk/rbeaumont/virtualclassroom/chap7/s2/dbcon1.pdf

Grooves P, Kayyali B, Knott D & Kuiken S (Jan 2013) The big data revolution in healthcare, accelerating value and innovation. Centre for US Health System Reform. McKinney & Company.

Michael McBride (July, 2012) Understanding the true costs of an EHR implementation plan. Medical Economics.

Ramez Elmasri & Shamkant Avathe (2003) Fundamentals of database systems. Fourth ed. Pearson. New York

Szolovits, P. (2003). Nature of Medical Data. MIT, Intro to Medical Informatics: Lecture-2. Retrieved on August 12, 2009 from http://groups.csail.mit.edu/medg/courses/6872/2003/slides/lecture2-print.pdf

Versel Neil (September, 2011) 12 EHR Vendors That Stand Out. InformationWeek Healthcare.?

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Intellectual Property in Electronic Health Records

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Intellectual Property in Electronic Health Records

Introduction

As a nurse, one comes into contact continually with issues of electronic health records. The Health Insurance Portability and Accountability Act is one of the Acts of the Federal Government that attempt to speak to the question of e-health records and classification of it as intellectual property. In this case, it is required that in the provision of cover for Americans, there is need to have a catalog of information kept by the health care providers which can be used in the offer of health covers (Hiller et al, 2011).

The HIPPA provides for mechanisms of protection of such information that is intellectual property by the privacy rule which demands that Personally Identifiable information ought not to be disclosed unless within the framework provided for under the Act (Bates, 2005).

Background

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Findings

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Procedure

References

Bates, D., 2005. Physicians and ambulatory electronic health records.”. Health Affairs, 24(5), pp. 1180-1189..

Mason, A. T. a. G. S., 2015. . American constitutional law: introductory essays and selected cases.. 1 ed. New York: Routledge.

Zittrain, J., 2000. “What the publisher can teach the patient: intellectual property and privacy in an era of trusted privication.. Stanford Law Review, pp. 1201-1250.

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Health Record Policies

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Health Record Policies

Evaluate the two policies in the attached “Health Record Policies” by doing the following:

Discuss what information should be included in an addendum pertaining to a shadow chart.

Generally, an addendum includes amendments or corrections in the primary medical records.This must bear the client’s signature, the amendment date and the amendments themselves. This avails the information that was missing at time of original entry.

Discuss how information technology staff can help decrease incidents of security breaches.

Security breaches especially related to data cause negative consequences for healthcare institutions, their clients and employees. The information technology staff should take preventive measures to avoid this. Encrypting confidential data is essential. All computers in the organization must have password protection. Also a backup of all data must be kept to avoid loss of data in case of data loss.

Thirdly, controls must be placed on data access and storage to avoid unauthorized access. Disposal of outdated data and equipment should be done carefully, and there should be regulation on use of laptops and other portable storage media and devices (Pendrak & Ericson, 1998).

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Discuss one situation from Montana Code 41-1-402 (2a through 2d) that may result in criminal liability to the organization if not followed.

A situation that may result in criminal liability for a healthcare institution is if for example an abortion is procured on a minor from a stable family and under the care of her parents without the parent’s consent.

Summarize how HIPAA defines criminal liability.

HIPAA has put a penalty for any unauthorized access to a patient’s medical records with or without knowledge of this law. Employees in healthcare institutions can also be charged with breaching the confidentiality of patients without authority to do so.
Explain which part of 2a through 2d of Montana Code 41-1-402 would directly impact actions of clinical staff.
Part 2 (d) would impact actions of the clinician. If a minor needs treatment for STDs, drug and substance abuse, then if the clinician accepts to offer treatment, they are also mandated to offer counseling the minor or refer them to a counselor.

Health Record Policies

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Discuss one situation from Montana Code 50-16-603x (1 through 7) specific to health record identification that may result in a legal claim against the organization if not followed.

If a healthcare institution uses pictures of their former patients for its advertisement on the media without written consent from the former clients.
Develop a confidentiality policy statement (suggested length of 1–2 sentences) using either Montana Code 41-1-402 or Montana Code 50-16-603.

Disclosure of a patient’s presence: This should not be disclosed to unauthorized parties, even in a manner that would reveal nature of disease without the consent of the patient as it will be a breach of confidentiality.

Compare three points in the Montana codes to HIPAA laws as they refer to release of information.

50-16-542. 1(a) Release of information will be denied if the healthcare provider thinks it will cause negative effects on the recipient. 50-16-542. 1(c) if the information will cause danger to the recipient’s safety and 50-16-542. 2(a) if the minor has a mental condition. All these show that information can only be released if it will not cause any adverse effects on the patient.

Health Record Policies

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Develop a release of information policy statement (suggested length of 1–2 sentences) using either Montana Code 50-16-541 or Montana Code 50-16-542 for a policy book.

Releasing information of patient over the phone of fax: This is not encouraged as the there is no evidence provided to show that the caller or fax destination are eligible recipients of the patient information.

References

Pendrak, R. F., & Ericson, R. P. (1998). Information technologies need to protect patient confidentiality.Healthcare Financial Management, 52(10), 66-8. Retrieved from http://search.proquest.com/docview/196382179?accountid=45049;

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