Over the past five decades healthcare record keeping has been evolving. In order to protect patient's records and encourage healthcare providers to keep up with current technology trends several federal agencies have been developed. As a result of these agency formations several laws and regulations have been put into place.
The development of healthcare information technology (HIT), and subsequently the rules and regulations, began to evolve in the 1960's with the development of Medicare and Medicaid under President Johnson. At this time a major reason for the development and evolution of health records and later, electronic health records, is healthcare reimbursement. Proper documentation and data tracking needed to take place to insure proper reimbursement. As we are seeing now with "Meaningful Use", the development and evolution of HIT deals with money and reimbursement. Over the last five decades health care records have evolved from paper and pencil to electronic health records (EHR). There were multiple problems associated with paper based records which led to the development of EHR in hoped to eradicate these errors. Some of these problems, that EHR resolves are: illegible writing, incomplete, inaccurate notes, the record being in only one place, records taking up a lot of space and difficulty of collecting and aggregating information across patients, providers and organizations (Buchbinder and Shanks).
The development of computers over the 1970's and into the 1980's took electronic medical records to a whole new level, making computers more affordable and computer programs more available. Healthcare IT took off in the 1980's with the development of local area networks and subsequently in the 1990's with the world wide web. These developments in technology led to more resources and accessibility to physicians and healthcare providers by such means as "physician portals" in which the patient can view their records and has better communication with their healthcare provider means such as email (Wagner, Lee and Glaser). With the development and evolution of EHR, and thus furthering the technology, laws needed to be put into effect in order to protect patient's data and minimize data tracking errors. Carlos Leyva describes Health Care IT Law on his website, www.lawtechtv.com, as "health informatics law deals with evolving and sometimes complex legal principles as they apply to information technology in health-related fields. It addresses the privacy, ethical and operational issues that invariably arise when electronic tools, information and media are used in health care delivery. Health Informatics Law also applies to all matters that involve information technology, health care and the interaction of information. It deals with the circumstances under which data and records are shared with other fields or areas that support and enhance patient care."
In 1991 the Institute of Medicine brought international attention to problems with paper based records and called for the adoption of computer based records. The computer based records were defined as "an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids (IOM, 1991, p. 11). Five years after the IOM's paper the Health Insurance Portability and Accountability Act (HIPAA) was signed into law. HIPAA was designed to lessen the costs of insurance, as well as make it more accessible, it also included provisions to protect the confidentiality of patient's records (Wagner, Lee and Glaser). In order to protect patient's records HIPAA requires healthcare entities to: install safeguards to protect personal information, limit access to who can view personal information and limit usages and access to records to the minimum to accomplish the treatment (HIPAA). Prior to HIPAA there were no...
Meaningful Use (2014). 2014 Definition Stage 1 of Meaningful Use. Retrieved June 26, 2014: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html
Srinivasan, D. Impact of Healthcare Informatics on Quality of Patient Care and Health Services.Boca Raton: CRC Press. 2013.
Wager, K., Lee, F., Glaser, J. Healthcare Information Systems. (2nd ed.) San Francisco: Jossey-Bass. 2009.
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