Patient Consent: Three Acceptable Methods for Electronic Records

Although the EHR is still in a transitional state, this major shift that electronic medical records are taking is bringing many concerns to the table. Two concerns at the top of the list are privacy and standardization issues. In 1996, U.S. Congress enacted a non-for-profit organization called Health Insurance Portability and Accountability Act (HIPAA). This law establishes national standards for privacy and security of health information. HIPAA deals with information standards, data integrity, confidentiality, accessing and handling your medical information. They also were designed to guarantee transferred information be protected from one facility to the next (Meridan, 2007). But even with the HIPAA privacy rules, they too have their shortcomings. HIPAA can’t fully safeguard the limitations of who’s accessible to your information. A short stay at your local

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 purpose of this discussion board is to describe the Electronic Health Record (EHR), the six steps of an EHR and how my facility implements them, describe “meaningful use” and how my facility status is in obtaining it, and to further discuss the EHR’s and patient confidentiality.

Electronic health records were a technological advancement in the healthcare industry in which paper patient record’s became digital. The transition from paper to digital charting allowed easier, quicker access to patient information for those who were authorized to do so. EHRs are secure and protected with username and password access only. It contains information such as patient medical history, procedures, diagnoses, medications, labs, tests, and treatments. Healthcare professionals and organizations who are authorized to access a patient’s electronic health record can do so at ease via a secure network or online database (HealthIT, 2013).

Patient portals are designed to allow the patient to see parts of the medical record. However, the majority of portals do not push the entire medical record into the portal. The reasons for this decision vary from system to system. There are two reason, while valid, do not allow the patient to become a full participant in healthcare. The first is security and access. Security pertains to mobile and web based use and how to protect the information. Access pertains to how the information is accessed and whom. The second is medical information sensitivity. This can become complicated and, in some cases, cause mistrust from the patient .The patient has the

When external requests come from an acute care hospital or nursing home for the release of information (ROI) for a patient’s medical records, various procedures take place. The ROI clerk must be knowledgeable of all the federal and state regulations and any laws that are involved. Whether it is paper-based, hybrid, or electronic, the procedure is still the same. The patient must sign a consent form or letter of authorization and must be accompanied by the request form to have any documents released. Upon receiving this request, the ROI clerk enters the request in a database to log the request, then needs to ensure the forms are valid before the patient information is released. Once the patient has been verified, then, only the specific information

Today, the patient will visit the same doctor and the doctor will enter the data into a tablet or pc. The EHR is a designed very similar to the paper chart, but is programmed to collect and segregate the information in different formats to transmit securely to the necessary partners. Those partners include insurance carriers, public health entities, clearinghouses, laboratories, and pharmacist. This data is collected and stored on secure servers. In most EHR’s today, a doctor who has a private practice, and maybe affiliated with a hospital has the ability to allow the hospital to access a patient’s record, if that patient has agreed to release their information to the hospitals. So if the patient is taken to the local hospital, the hospital can have access to the patient’s records if an authorization is in place. The EHR will not only collect the patient medical information, it will track the medical information. Providers are required to secure the information and track the medical records activity via a built-in audit system that will show the medical records history and the name of all parties that access the patient’s records. Poor EHR system design and improper use can cause EHR-related errors that jeopardize the integrity of the information in the EHR, leading to errors that endanger patient safety or decrease the quality of care. These unintended consequences also may increase fraud and abuse and can have

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Implementing to electronic medical records has many benefits such as reducing medical record errors, accuracy, having medical record access immediately, reducing medication errors and improving patient care. Monetary incentives are given to providers who demonstrate meaningful use. For those who do not, they face reduction in reimbursement amounts. “In 2017, reduction in reimbursement is 3%.” (National Center for Medical Records, n.d.)

There are different types of consent that can be gained by individual for a treatment to be carried out, for example, expressed consent can be given either written or in a verbal form (Tidy 2016a). Verbal consent can express through words, for example, agreeing for a blood pressure measurement to be taken (Farlex, 2003). Written consent is a legal documentation through the individual’s signature stating that they comply with treatment. Implied consent is the assumption that the patient concurs with the treatment as they haven’t denied it (NHS Scotland 2016). If a patient is unconscious there is no information or statement nearby to suggesting a decline of a treatment e.g. Religious reasoning for not taking a blood test, health professionals

Constantine A. Manthous’ article Counterpoint: Is it Ethical To Order “Do Not Resuscitate” Without Patient Consent? looks at the issues of withholding life-sustaining therapies, such as CPR, in cases where these therapies will only prolong the suffering of the patient. Manthous begins his argument by stating that CPR, which is often ineffective, remains the only medical procedure in cases of cardiac arrest. Manthous goes on to state that a doctor issuing a “Do Not Resuscitate” order unilaterally is unethical, as it deprives the patient of their right to self-determination. Only after receiving informed consent from the patient is the issuance of a DNR order ethically appropriate.

Dr. Kemp defines an electronic medical record (EMR) as “the digital version of a paper chart that contains all of a patients ' medical history from one practice” (Kemp, 2014). He also differentiates between the use of the term electronic medical record (EMR) and electronic health record (EHR). An EHR is more “comprehensive” than an EMR. It allows for data sharing across multiple practices. The use of both EMRs and EHRs has gained in notoriety in the last decade. And it appears that the use of these two terms is interchangeable. The idea of data sharing and having one’s health records at the click of a button is highly appealing. While there are several ethical implications to explore when dealing with computerized charting, the objective for this research review will focus primarily on three interesting concepts: autonomy, finance, and privacy, as it relates to information technology.

What are some bioethical challenges regarding the consent process for organ transplantation? Health care providers have a commitment to respecting a patient’s right to donate an organ and an obligation to ensure the patient provides informed and voluntary consent for the procedure. Does this consent process differ from the consent needed to provide health care to a patient in other situations? I will be doing a research on giving consent, in the medical profession there are many regulations and legal aspects when a patient gives consent for any type on service.

The scenario selected for this evaluation project focuses on the electronic health record. The scenario involves patient documentation, clinical decision support, and performing nursing notes. The project involves evaluation and implementation of EHR. The electronic health record and clinical decision support are not only relevant to my current organization but also are particular interest of mine. The electronic health record has helped to reduce the amount of paper which was a nightmare to maintain with the number of new patients being admitted daily. The electronic health record has also reduced the amount of missed documentation and errors. Any clinician can testify to the wasted time and poor communication among providers that sometimes results because antiquated paper records still predominate in our offices and on the hospital wards (Shortliffe, E. H., Tang, P. C., & Deimer, D. E., 1991). The clinical decision support system has been a great assistance to clinicians. Nurses, health visitors and midwives, as the largest group of healthcare professionals, record and generate most of the information used to maintain and improve patient care (Levy, S., & Heyes, B., 2012). Clinical support systems (CDSS) integrate information (ideally from high-quality research studies) with the

In a world full of electronics it would only seem logical to have health records electronic. Not only are medical records efficient, reliable, and quick to access, new technology allow patients to access their own personal medical records with a simple to use login and password. “People are asking whether any kind of electronic records can be made safe. If one is looking for a 100% privacy guarantee, the answer is no”(Thede, 2010). At my hospital, upon every admission we ask the patient for a password for friends and family to have to have if they would like an update on the patient 's condition. We do not let visitors come up and see the patient without the patient 's consent. In doing these things, we help to ensure the safety and protection of the patient 's health information and privacy.