Clinical Health Information Analysis

The purpose of this paper is to discuss the electronic health record mandate. Who started it and when? I will discuss the goals of the mandate. I will discussion will how the Affordable Care Act ties into the mandate of Electronic Health Record. It will describe my own facility’s EHR and what steps are been taken to implement it. I will describe the term “meaningful use,” and it will discuss possible threats to patient confidentiality and the what’s being done by my facility to prevent Health Information and Portability Accountability Act or HIPAA violations.

The Health Insurance Portability and Accountability Act (HIPAA) was passed by congress in 1996, and helps to ensure the privacy and security of Electronic Health Records (EHR's). By following the rules and regulations set forth under HIPAA, we can ensure the safety of patients' EHR's. We are responsible for protecting patients' records, and there are many measures we can take in order do this. Firstly, we must always keep patients' health information private. This means no discussing the records with people that are not authorized to know, and even then, we should only disclose the minimum necessary amount of information possible. For covered entities, we must designate a privacy and security officer to ensure the privacy

There will be information at hand to assist in making medical decision during the time of visit. Lastly, the EHR mandates that people’s health information is to be kept secure ("Department of Health and Human Services," 2008).

In 2009, the Health Technology for Electronic and Clinical Health Act (HITECH) of 1996 was expanded. This expansion included mandated guidelines for health care systems in the Unites States to continue implementing of Electronic Health Records (EHR) in health care settings by 2016 and added a provision to improve protection of patient health information through privacy and security Turk (2015) . The implementation of this program has created a debate in the medical community. In addition, many healthcare organizations and institutions have conducted research studies and surveys to evaluate the effects of the EHR on documentation of care and other aspects of the EHR. Challenges surrounding the HER include, the cost of implementing EHR’s, time spent performing documentation, and patient outcomes and safety and security concerns. Let’s further delve into a few of these challenges.

The federal requires the healthcare organizations to adopt and demonstrate the use of electronic medical records (EMR) or the electronic health records (EHR). They contain patient’s medical history and it

Health information exchange (HIE) delivers information when and where it is needed to provide improvements in healthcare quality and efficiency. HIE requires essential coding standards throughout health information management so that information can be accessed, merged, divided and/or shared with other healthcare organizations. In order to reach interoperability; message, exchange, and terminological standards are a few key attributes needed. HL7 v2, CDA and RxNorm aid in reaching these standards to achieve HIE.

The Continuity of Care Record (CCR) is a fundamental data set of pertinent administrative, demographic, and clinical evidence that provides details about a patient’s healthcare encounters (American Society for Testing and Materials (ASTM), 2014). CCR structure provides electronic formatted structure that can be interchangeable with other electronic medical software and provides mapping of patient’s health information. The primary usage of CCR provides a standard format of health data transmission of information that can be looked at from the patient, physicians, and other providers. CCR structured called the eXtensible Markup Language (XML) offers a summary of the patient’s health records where the output can create into sources such as health plans, personal health record (PHR), electronic medical record (EHR), and many other sources of data (ASTM, 2014). For instance, CCR XML files provide patient’s insurance information, care plan, vital signs, laboratory results, medical equipment, providers, medications, and many other important medical data about the history of the patient’s health (book reference, 2010).

The current push for widespread implementation of a certified EHR is somewhat of a mess. Many healthcare providers did not want to change from their current methods. Without making the change, they risked the possibility of consistent (yearly) financial penalties for not adhering to standards. Certified EHRs have the ability to revolutionize healthcare. As every knows EHRs are a great tool for improving the quality of care. The information that EHRs contain can be collected to conduct meaningful research in order to improve clinical, organizational, and societal outcomes. In regards to legal situations EHRs will hold all evidence relating to complaints of medication error, malpractice, etc.

The EHR and/or PHR and HL7 are needed tools that help to improve patient care and safety. EHRs and PHRs help healthcare providers in the exchanging and collecting of patient data. Both record types also exchange health data between various healthcare settings (ambulatory, long term, etc.), providers, patients, and other organizations. When records work in conjunction with HL7 standards the exchange of information is consistent and widespread. In the final rule of “meaningful use” stage 2 the use of HL7 in records helped to improve patient summaries, clinical messaging, electronic prescribing, and transportation details. HL7 allows all EHRs and PHRs the ability to communicate not on just a locally but on a global scale which will in turn provide

The preferred format for clinical health information is Health Level Seven (HL7) Clinical Document Architecture (CDA) for both Personal Health Record (PHR) and Electronic Medical Record (EMR). It is XML-based format identifies the encoding, configuration, and semantics of a clinical file. Blue Button+ Direct implementation ensures ease of transmission of medical records to a third party by the health care provider or patient. Direct uses SMTP, S/MIME, and X.509 licenses to maintain security, data reliability, privacy and verification of sender and receiver. Additionally, it meets the requirements for Meaningful Use (MU) Stage 2 of View, Download, and Transmit (VDT) that is required for certified electronic medical record (EMR)

Clients medical history, orders, and vital signs can be obtained by using medical informatics. Obtaining health information includes electronic devices such as electronic health records EHR, electronic medical records EMR, and MyChart. Paper charts are another way that can be used by health care providers to obtain necessary information.

When documentation of patient medical records began, patient information was documented by a nurse and communicated to a doctor and other health care team members by means of handwritten charts. Accuracy of patient information depended upon the legibility of the documentation, and it is a widely known stereotype that a doctor’s handwriting is messy and indecipherable. These charts, because of their handwritten nature, have resulted in an estimated annual 98,000 deaths due to misunderstandings (Allen, 2013). As the technology became more advanced, it became of great importance to ensure proper communication amongst health care team members and to prevent unnecessary deaths.

EHR allows health carre professionals to view and update patient’s record, these records are available to authorized health care professionals only [8].

The data was collected by the health IT supplements to the American Hospital Association’s annual survey which was self-reported and hard to verify the accuracy of the responses. Also the authors could not make sure if the result of the survey was biased depend on the respondents with their different attitude when they were taking this survey.

Physicians are apprehensive about the validity of data entered by patients. Thus, “…existing medical information should not be reentered into a PHR but rather that medical records, should be shared, with PHRs being one access point” (Witry, Doucette, Daly, Levy, & Chrischilles, 2010). Hence, a solution may be installing a health information exchange system to achieve this. Fictitious health data in a PHR might imply the need for narcotics when a patient visits an emergency department. However, this is the wrong call. According to Witry, Doucette, Daly, Levy and Chrischilles (2010), “…PHRs should draw verified information from the patient’s medical record”. This will prevent erroneous errors from occurring.