Introduction

Data refers to raw facts or figures collected primarily from the field or secondarily from the review of the literature. Data must be collected, recorded, analyzed then presented to have meaning. When the client arrives, data is collected for clinical use, billing and research purposes. Withthe advancement in information technology, there has been a shift to electronic records. This has several advantages which will be spelled out in this paper.

Information, as used in this paper, refers to processed data which has meaning. An information system refers to a combination of hardware and software for collecting, recording, analyzing and processing data into information. An information system aims at creating access and value to data. The paper begins by describing the electronic health record used in my practice and ends by stating the regulations to its use.

Electronic Health Records (EHR) Platform used in my practice

Principle

Electronic health record system was adopted six months ago at our practice. We use a database designed to be patient-centered, simple to use and cost effective. It is hinged firmly on the principles of equity. The system’s motto summarizes this succinctly: “Treat the Patient, we will handle the records.”

Confidentiality is maintained in the EHR since access is only granted to the staff using a username and a password. Autonomy of the client is ensured through recording the patient’s views and preferences. The data collected cannot be saved without filling this segment.

Secondly, there is interoperability of the records between departments. The data obtained from one department on the same client is readily availed to other departments since the system assigns a unique number to the client.

The electronic health records architecture

The system used was acquired from a software development company based in the locality. It involves a conjoint server to which other computers within the network are connected. The data obtained is backed up both within the facility and in the cloud. Data is recorded into the system by various professionals. These include secretaries, physicians, nurses and the patients themselves.

The system precisely charts the data components required. These include client demographic data, medication, nurses and doctor’s notes, referral, management plans, diagnoses, tests, and procedures. Additionally, complete patient history, physical examination, and investigations are required.

The EHR also incorporates a patients’ complaints portal where they can post their concerns. This portal ensures patient participation in their care which has been shown to improve health outcomes. It also gives room for further improvement in the system in the face of the dynamic changes in society (Asan, 2016)

The EHR is available to all clinical units and the departments within the facility including the financial, legal and occupational safety departments. This leads to efficiency and cost effectiveness in service delivery.

Why the move from paper to electronic charting

An electronic health record is preferred to paper records because they are cost-effective since they save on the resources that would be incurred to establish a paper records system. Moreover, interoperability leads to fast access to information. The turnaround time between the recording and presentation time is shortened which further improved access. The EHR provides accurate and extensive client information.

Additionally, EHR enhances environmental conservation by reducing the need for paper.  Furthermore, the doctor-patient contact time increases as the doctor focuses on the patient due to the provision for audio recording in the system.

EHR is known to save time, a vital resource for the hospital. They enable scheduling of appointments, billing, prescribing and access to the results if previous investigations and procedures (Ventola, 2014).

EHR leads to the legible and broad charting of data which simplifies billing. Legible records reduce errors like wrong procedures or prescriptions. That EHR improves safety and confidentiality is undoubted. The requirement for passwords and access to the system ensures this. Data back-up confers safety and indefinite storage even if fire and otheraccidents destroy the hospital (Rolim, 2010).

Lastly, EHR leads to the use of appropriate tests, provision of proper care and facilitation of patient communication which leads to involvement of the patient in their care and augments compliance (King, 2014) (Woods, 2013).

Barriers to the use of electronic health records

Security infringement by unauthorized personshas reduced the adoption of electronic health records since it impinges on client confidentiality. To ward off intrusion, antivirus and detection software’s can be used. These are expensive (Ozair, 2015).

The adoption and execution of the EHRare problematic for doctors, nurses, and secretaries. Frequent updates to the system without education of the users leads to little understanding of the EHR (Ozair, 2015).

Data inaccuracy often occurs in electronic health records. For example, illegal entries and damage during transfer may lead to wrong treatment, litigation and added costs (Ozair, 2015).

Regulation of Electronic Health Records

These are measures meant to control the barriers to the adoption of electronic health records. First, the use of passwords, firewalls and intrusion detection applications prevents security breakage.

Privacy policies that give the patient complete control of the information stored. Organizations seeking this information must get express consent from the patient. The Health Insurance Portability and Accountability Act (HIPAA)affirms the patient’sright to privacy. The act also provides for access to health records by the patient and informed consent (U.S Department of Health and Human Services, 2019)

The health care professional must be aware of these regulations to improve the adoption of the electronic health record, save on time and costs and to avoid litigation.

References

Asan, O., Tyszka, J., &Fletcher, K. E. (2016).Capturing the patients’ voices: Planning for patient-centered electronic health record use.International journal of medical informatics, 95, 1-7.

King, J., Patel, V., Jamoom, E. W., & Furukawa, M. F. (2014). Clinical benefits of electronic health record use: national findings. Health services research, 49(1pt2), 392-404.

Ozair, F. F., Jamshed, N., Sharma, A., &Aggarwal, P. (2015). Ethical issues in electronic health records: a general overview. Perspectives in clinical research, 6(2), 73.

Rolim, C. O., Koch, F. L., West Hall, C. B., Werner, J., Fracalossi, A., & Salvador, G. S. (2010, February). A cloud computing solution for patient’s data collection in health care institutions.In eHealth, Telemedicine, and Social Medicine, 2010.ETELEMED’10. Second International Conference on (pp. 95-99). IEEE.

U.S Department of Health and Human Services, H. (2019). HIPAA. Retrieved February 11, 2019, from https://www.hhs.gov/: https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html

Ventola, C. L. (2014). Mobile devices and apps for health care professionals: uses and benefits. Pharmacy and Therapeutics, 39(5), 356.

Woods, S. S., Schwartz, E., Tuepker, A., Press, N. A., Nazi, K. M., Turvey, C. L., & Nichol, W. P. (2013). Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: a qualitative study. Journal of medical Internet research, 15(3).

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