Introduction Hospitals and other health care providers increasingly rely on cutting-edge technology to provide medical treatments to patients, and a growing number also realize the benefits of technological advances in administration and record-keeping. In the recent past, most health care providers maintained patient records in paper files, eventually transferring the completed records to microfilm for safekeeping. Many providers now, however, use computers and computer networks, microwave technology, facsimile machines, and optical scanning and storage equipment in the creation, transmission, storage and retrieval of medical records.
Although a computer based patient record system can improve efficiency and the quality of care rendered by a provider, it may also increase a health care facilities exposure to liability under many of the legal theories or causes of action traditionally associated with health information management. It generates unique confidentiality and integrity concerns; for example, it increases the risk of improper disclosure of personal health information and computer sabotage of persons gaining unauthorized access to a computerized record system.
There are a number of issues, more of an ethical rather than technological concern regarding electronic health records. An EHR is defined as a longitudinal collection of electronic health information that provides immediate electronic access by authorized users. (HIMSS) An EHR may involve knowledge and decision support tools that enhance safety and efficiency as well as support of efficient processes for health care delivery.
As new advances in technology occur and the value of large databases of clinical data continues to grow, the conversion of records from paper to a computerized format will remain a dominating trend in health information management in the decade to come. Health care reform initiatives and the increasing penetration of managed care into the health care delivery system have further heightened the need for comprehensive automation and the automated need for health care information.
Whether it is to monitor costs, improve patient care, or evaluate participating health care professionals, the basis is in gathering and sharing health care information. In a managed care setting, confidential patient information is frequently linked through databases that allow participating providers to access all the clinical data about a patient who may have received treatment at a variety of points of service within an integrated delivery system. In this environment, paper record systems that were provided based are being replaced with electronic medical records.
Computerization of a providerâ€™s records can enhance quality of care by permitting quick capture of information in a patientâ€™s record and by improving access to a patientâ€™s records by the many health professionals who may be involved in his care. In addition, quality improvement and quality assurance programs can be strengthened with the help of automated record systems. One basic risk prevention technique involves determining who has access to what information for what purpose at which times. (McWay, 2003).
Automated record systems create the possibility of linking the patient record to expert diagnostic systems and other electronic decision support tools to further enhance the quality of patient care. A fully integrated computer based record system can also increase efficiency by reducing the volume of paperwork required for admissions, order entry, reporting of results of radiological examinations and laboratory tests, pharmacy dispensing. This in turn diminishes the overall time spent on updating and filing the records.
In addition a computerized record system can assist with patient scheduling. Although a computer based patient record system can improve efficiency and the quality of care rendered by a provider, it may also increase a health care facilityâ€™s exposure to liability under many of the legal theories or causes of action traditionally associated with health information management. Inadequate system security reflects the potential for large-scale breaches of data security in a computerized medical record system.
Electronic data exchange has also opened the door to new kind of health care fraud, arising from the growing number of computer links to claims information and the addition of electronic fund transfer capabilities. According to Forty percent of surveyed U. S. adults think that electronic health records will have a “somewhat negative” effect on the privacy of personal information and health data, while 20% believe EHRs will have a “somewhat positive” impact on the privacy of personal data, according to a new survey from CDW Healthcare. Moehrke, 2011). Conclusion Millions of individual medical records float around these days in a vast electronic network that serves both commerce and scientific research. The information navigates around the country, speeded by computers. Computers help diagnose patients; enhance quality of care; improve access; increase efficiency; and conserves time. One of the main reasons that there is such a big national movement toward electronic medical records is the increasing evidence that they improve patient safety.
Preserving the confidentiality, integrity, accessibility, accuracy, and durability of records on an automated system should be prioritized. Finally, it is vital that computerized record systems be designed, installed, and maintained in a manner that preserves the reliability of records created and stored on such systems. Whether the health care provider chooses a traditional paper-based patient record or electronic record, the same legal requirements apply: the record must be kept secure and guarded from unauthorized access.
Works Cited HIMSS. (n. d. ). EHR Electronic Health Record. Retrieved April 28, 2011, from www. himss. org: http://www. himss. org/ASP/index. asp McWay, D. C. (2003). Legal Aspects of Health Information Management, Second Edition. In D. C. McWay. Clifton Park: Thomson Delmar Learning. Moehrke, J. (2011, March 13). Healthcare Security/Privacy. Retrieved April 28, 2011, from www. healthcaresecprivacy. blogspot. com: http://healthcaresecprivacy. blogspot. com/2011/03/ healthcare-privacy-why-are-patients. html
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