Running head: ELECTRONIC MEDICAL RECORD AVAILABILITY
Electronic Medical Record Availability
University of St. Francis
Electronic Medical Record Availability
Electronic medical records are becoming more and more prevalent in the hospital environment. Physicians meet this reality with mixed feelings; they do want the increased availability of patient history, but they also want a system that takes the same amount of time or less to complete their documentation. The electronic medical record also creates challenges for management of the records for the hospital system. When the medical record is a voluminous pile of paper, the ownership of the record is fairly straightforward, he who possesses the pile of paper is the owner of that, and any data originated elsewhere is in the pile as a copy and not the original data set. Now with the electronic version, it becomes less clear, especially, if we consider the future of interfacing hospital records and physician office records. If we have a medical record showing the hospital visit information, and electronically linked to that is the history and physical from the surgeon’s office prior to admission, then who owns the history and physical? If the patient presents at the hospital to obtain a copy of their medical record; then, you can only give them what you own. If the history and physical are required but obtained via electronic harvesting, then the system it was harvested from should be the legal owner and responsible for recordkeeping. What does this mean for the patient? They will have to go to multiple locations to obtain copies of the complete record that is available at the hospital but not owned by that facility.(Veronesi, 1999) The next challenge is controlling access to medical records. When you have the pile of paper, it can be contained in the nursing station or locked in the medical records department, and access is very obvious. If an unknown person enters the nursing station, and retrieves your patient’s chart, the care team would challenge the access rights of that person. This would occur whether or not the person is an employee. Now, consider the same situation with an employee sitting at a computer terminal on the 2nd floor doing his job. He can easily look up his neighbor’s record on 5th floor without anyone in that area knowing the record has been reviewed or that their patient’s rights have been violated. (Veronesi, 1999) The security of the medical record is a juggling act between access for appropriate and timely medical evaluation and treatment and protecting patient privacy and HIPAA compliance. All physicians on staff should have access to any medical record of any patient, not just their patient or patients they are treating in the facility. This is because they are a doctor first and provider second. It does not matter if it is his patient or that of his competition. If the patient in room 15 is in crisis and the physician is present, he will treat and need access to all of the data to safely do so. A variety of tools are applied, such as, audit trail analysis, unique identifiers for each user, time-sensitive password systems, encryption, and access restrictions based on job type. This has also created a new profession of information technology security specialists in healthcare, which includes the security of hand held computer systems, whether hospital or physician owned, with access to the medical record. (Ebell & Rovner, 2008) Security in the electronic media is less physical barrier and observation, such as locked doors and security cameras; while this is important, the new system can be accessed remotely without ever entering the physical building where the data is housed. Network monitoring and access control while reviewing audit trails are now required. Also, we need triggers, such as for an insurance clerk reviewing the radiology records for one...
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