Presented by Jamie
• EMR systems give immediate access to medical records. You do not have to wait around for medical records to pull out old charts or in some cases we don’t have to wait for another facility to find and send over the information.
• Gives the staff the ability to read the chart anywhere if needed and not have to try and translate what someone wrote if the writing is not very neat, and helps to cut down on spelling errors and charting completion.
• Mr. Smith comes into the ED unconscious. The staff does not remember him but they find an ID on him. They type his name into the system and find that he is a type 1 diabetic from his medical history in the doctors office so they can immediately start checking to see how his diabetes is controlled. As a result they find that he was in DKA and were able to start treatment sooner.
• Staff in the past have had to have the chart in order look at the patient chart, now with computer charting we have to be very careful not to look at charts of patients that we are not taking care of. With the user sign on it is easy to determine who was looking at different charts which can cause a HIPAA violation.
According to Summary of the HIPAA Security Rule • Specifically, covered entities must: • • • • Ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain or transmit; Identify and protect against reasonably anticipated threats to the security or integrity of the information; Protect against reasonably anticipated, impermissible uses or disclosures; and Ensure compliance by their workforce.4
The Security Rule defines “confidentiality” to mean that ePHI is not available or disclosed to unauthorized persons. The Security Rule's confidentiality requirements support the Privacy Rule's prohibitions against improper uses and disclosures of PHI. The Security rule also promotes the two additional goals of maintaining the integrity and availability of e-PHI. Under the Security Rule, “integrity” means that ePHI is not altered or destroyed in an unauthorized manner. “Availability” means that e-PHI is accessible and usable on demand by an authorized person.5
Personal Health Information
We need to be very careful when accessing and charting on patient records. With the push of one wrong button we could post multiple patients records either on the computer or by fax. It is also possible to have more than one patient record open at a time which could mean that you are charting on the wrong patient with another patients information. Then that information is sent to the wrong insurance company or if that patient asked for medical records they could get another patient information. This could also lead to malpractice because we treat something for one patient when it should be on another patient.
Personal Health Information cont.
• • • • • It has been found that people are looking up their friend, family, neighbor etc. chart to “make sure they are ok” otherwise known as snooping into another persons chart. We are not to do this as it is a breach of confidentiality. Breaches can also occur by equipment missing or stolen. If you use one of the laptops you must sign off when leaving it due to this threat. If someone sees it lying around and was to take it they could do a lot of damage to you, the patient, or the company. According to Personal Health Information Breaches Most Often Caused by Insiders? One of the studies showed that 71% of organizations in health-care have had at least one breach in the past 12 months. It also states that out of the 71% of organizations that have the breach 25% of them are because of loss or theft of those records. As this tells us it is not only famous people or big people in the community that we are looking up, it is going to be just someone looking someone up that they are not supposed to be. This is...