Electronic medical record (EMR) is necessary in the health care system for high quality and safer care by exchanging health care information electronically. It enables getting quick access to accurate and up-to-date information of patients and promotes effective diagnosis of patients and minimizes chances of medical errors (King et al., 2014). Despite numerous advantages of EMR in improving quality and efficiency in care, many health care organization are reluctant to implement EMR. The main reasons for this are as follows:
The Health Insurance Portability and Accountability Act (HIPAA) was mainly implemented to protect health insurance coverage for people who have lost or change their jobs. It also directs establishing national standards for processing and securing health care data. By this means, it plays a role in protecting and securing patient’s medical records. After the enactment of the Act, the federal law took the responsibility to maintain confidentiality of medical records and enforce high standards to protect confidential patient’s information. By considering the appropriate disclosure process for sharing or not sharing private medical information, it has played a role in improving health care service in all areas (Klein et al., 2016). Hence, with the Privacy rule in the HIPAA, patients got certain important rights with respect to disclosure and confidentiality of their health information
The Health Information Technology for Economic and Clinical Health Act (HITECH) was implemented in 2009 to promote adoption of electronic health record (EHR) and supporting technology in United States. It mainly aimed to incentivize health care providers to adapt HR and use them in a meaningful way to reduce medical errors and additional cost in delivery of care. The advantages of HITECH Act for health care professional are as follows:
The disadvantage of adopting HIPPA for health care professional is that sudden implementation of HIPAA has affected health care professional’s work flow in the initial stage of implementation. The responsibility to handle and protect diverse patient related information through EHR has posed many challenges for health care professionals in the area of health information exchange. Many ethical and legal dilemmas have been experienced by the health care professionals due to inappropriate methods of adopting health information exchange (Vest & Gamm, 2010). Hence, this means that just technological progress cannot improve the quality of health information exchange (HIE), strategies are also needed to implement the barrier in adapting the technology.
The health information exchange (HIE) issue experienced by health care professionals in adopting the technology can be solved by leaving the organizational efforts and combining it with individual consumer based model. This will help them to achieve the objective of HITECH as well as promote complete provider participation in using EHR (Vest & Gamm, 2010).
The typical workflow process in health care organization consist of clinical documentation process to record new patient’s information and direct them to appropriate clinician and health care department, diagnosis process, assessment of patient and the appropriate care and treatment process following final diagnosis of disease. The clinical documentation process mainly relies on a combination of paper and electrical format. Hybrid system of duplicative paper and electronic records exist in health care organization. A survey showed very few organization captured patient information electronically (Smith & Haque, 2006). Hence, paper is a major form for organizing patient’s information in health care and without the lack of standardization of the information system, the clinical documentation process is risky and full of errors. Other disadvantage of depending on paper based format for managing critical patient’s information is that it is a very time consuming process as well as inefficient process. Hence, the process of clinical documentation and information exchange by means of paper based medical records needs to be replaced completely as it is seriously affecting the pace of work and other process involved in typical workflow process.
The lack of standards for a fully electronic documentation process and dependence on paper based medical record has been the reason for more chaos and inefficiency in the workflow process. In addition, paper records are takes up lot of space. A review of paper based medical records has shown that such data have lot of inconsistencies both on quality as well as its scope. This ultimately has an impact on the health care delivery process. The challenges and issues becomes high in case of patients with chronic illness because their treatment relies on historical data about life trajectory, changes in condition with time and types of treatment implemented for the patient. The hybrid paper/electrical medical record system also makes data coordination process very challenging (Smith & Haque, 2006). Hence, it can be said that there are very few benefits with paper based medical record system and large chances of issues in the clinical work flow process particularly for critically ill patients. In addition, after the enactment of the HIPAA and HITECH Act, adopting EHRs is a major responsibility for health care organization. However, paper documentation process acts as the main factor for the slow adoptions of EHRs (Heisey-Grove et al., 2014).
The above issue in the health care workflow process indicates that although electronic record system has been integrated in the health care system, however the usability of the system is affected by the presence of a hybrid paper and electronic system. There is a need to take adequate steps to eliminate the paper based medical record completely to enhance the data coordination process, improve timeliness and efficiency in delivery of care and promote patient safety. Ajami & Bagheri-Tadi, (2013) has pointed out that there are several barriers to adapting the EHRs system in health care organization. This comprise extra time and cost involved in using the system, poor computer skills, disruption in workflow process, security and privacy issues, communication among users and interaction problem with doctors and patients. To promote usability of the EHR, there is a need to effectively integrate EHRs into clinical workflow so that it can readily used during routine clinical documentation process. Another recommendation is to take account of all types of usability concerns before standardization of the EHRs system within the health care organization. Development of a common user interface style guide can also promote usability of the system (Middleton et al., 2013).
The enactment of the HIPAA and HITECH are example of some federal initiatives to improve the standard of health care information. The federal initiative focused on optimizing the use of EHR in health care environment, however they also realized the issues risk of authorized used and challenges in disclosure of confidential patient information. Considering the high challenges in maintaining confidentiality and balancing the need for privacy while using EHR, the federal made it an obligation to protect the confidentiality of patient health information according to HIPAA and HITECT Act. This ensures that organizational practices related to confidentiality, security and disclosure of patient information is consistent with regulations. It also promoted education of health care professionals to understand confidentiality and data security requirements (Ethical Policy Statement: Health Information Confidentiality, 2017). . In this way, federal initiatives have ensured proper integrity and safe management and exchange of health care information during the health care delivery process.
There are numerous advantages of applying IT system within health care organization. Firstly, it is cost effective as it has cut out lot of manual work and health care personnel gets easy access to patient data and health care information. Documentation and keeping records of patients was a major challenges, however implementation of electronic medical records has enhanced the retreivability of the data and improved data security. Another advantage is that the use of automated software and advanced technology according to health care organizations need has improved the efficiency in the delivery of care. The IT systems are automated and this ensures that large amount of task can be done without human intervention. With these changes, the scope of error has been reduced dramatically (Wager, Lee & Glaser, 2017). .
Some of the new IT development that can take placed in the health care environment in the coming two decades includes greater development of mobile health technologies such a wearable device to tracks patient’s health status and preventing wide range of disease. Although this type of technology is already available, however within 20 years they may more sophisticated and cost friendly too so that people with low socioeconomic status can also use it. New medical robotic device and implantable health IT system may also be interfaced to EHRs system to establish exceptional standards of care. This is likely to occur because current EHRs have not reached a stage where it can be used by all group of people irrespective of education and socio-cultural background.
References
Ajami, S., & Bagheri-Tadi, T. (2013). Barriers for adopting electronic health records (EHRs) by physicians. Acta Informatica Medica, 21(2), 129.
Ethical Policy Statement: Health Information Confidentiality. (2017). Ache.org. Retrieved 28 October 2017, from https://www.ache.org/policy/Hiconf.cfm
Fernández-Alemán, J. L., Señor, I. C., Lozoya, P. Á. O., & Toval, A. (2013). Security and privacy in electronic health records: A systematic literature review. Journal of biomedical informatics, 46(3), 541-562.
Heisey-Grove, D., Danehy, L. N., Consolazio, M., Lynch, K., & Mostashari, F. (2014). A national study of challenges to electronic health record adoption and meaningful use. Medical care, 52(2), 144-148.
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.
Klein, J. W., Jackson, S. L., Bell, S. K., Anselmo, M. K., Walker, J., Delbanco, T., & Elmore, J. G. (2016). Your patient is now reading your note: opportunities, problems, and prospects. The American journal of medicine, 129(10), 1018-1021.
Menachemi, N., & Collum, T. H. (2011). Benefits and drawbacks of electronic health record systems. Risk management and healthcare policy, 4, 47.
Middleton, B., Bloomrosen, M., Dente, M. A., Hashmat, B., Koppel, R., Overhage, J. M., … & Zhang, J. (2013). Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. Journal of the American Medical Informatics Association, 20(e1), 2-8.
Smith, C. A., & Haque, S. N. (2006). Paper versus electronic documentation in complex chronic illness: a comparison. In AMIA Annual Symposium Proceedings (Vol. 2006, p. 734). American Medical Informatics Association.
Vest, J. R., & Gamm, L. D. (2010). Health information exchange: persistent challenges and new strategies. Journal of the American Medical Informatics Association, 17(3), 288-294.
Wager, K. A., Lee, F. W., & Glaser, J. P. (2017). Health care information systems: a practical approach for health care management. John Wiley & Sons.
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