Electronic health records of patient offers enhanced communication and maintenance of quality of care between the healthcare professionals. It provides patient’s medical history and key clinical data of a person who is under a particular healthcare provider. There is a need to ensure documentation integrity as there might be invalid auto-population data field entry or manufactured documentation to enhance the reimbursement. There is also requirement of data integrity like ensuring security and privacy in health information that help to build trust and improve healthcare quality and equity in services. However, there are ethical and legal implications related to data integrity confronting health personnel like respect for autonomy, non-maleficence and beneficence along with privacy and confidentiality. Therefore, the following assignment deals with the legal and ethical implications in data integrity in electronic health records (EHRs).
Data integrity refers to the data quality where there should be maintenance and assurance of consistency and accuracy of data over the entire life cycle. The data entered in the healthcare records should be reliable and valid. There is a responsibility to protect data as it is of extreme importance in healthcare as it is used to identify, track patients when they move from one care level to another. At every level, healthcare data integrity is important as it help providers to make use of this data in taking decisions regarding patient care. Failure to protect data has serious impact on patient safety and poses risks. There might be wrong data entry, delayed, missing data delivery, or any sort of associated errors like data entry from another patient record (Huffman & Rittenmeyer, 2012). These pose serious implications on healthcare as poor EHRs system designing and improper use can cause errors in the electronic system that can jeopardise that information integrity in EHR resulting in errors and endangering patient safety and quality of care. Unintended consequences may increase abuse and fraud posing serious legal implications. It can contribute to the suboptimal quality of healthcare and error can occur from the improper system use. The faulty functionality of EHRs can mislead doctors and clinicians due to incorrect values or confusing screen display resulting from program error entering data of wrong medication or patient (Fowler & Davis, 2013).
Apart from healthcare delivery, data integrity affects the nursing care on a large scale. Nurses have the responsibility to protect patient information as it has a significant impact on overall healthcare system affecting communication and patient safety. They have the obligation to protect and safeguard patient rights as according to Code of Ethics for Nurses, American Nurses Association, they have the responsibility to promote and advocate patient privacy and confidentiality (Winland-Brown, Lachman & Swanson, 2015). Wrong entry in health records pose patient safety risk issues in every level of care, therefore there should be data integrity that safeguard patient safety and quality of care. The ethical implications include beneficence, non-maleficence and respect for autonomy. The patient is the owner of his or her information and nurses have the responsibility to protect data and share only relevant information with other healthcare professionals for clinical decision-making with prior patient consent (Johnstone, 2015).
Although, EHRs improve the quality of care, there are problems that affect the data integrity in healthcare system. The primary goal of implementation of EHR is to reduce medical errors that compromise patient safety and integrity (Ayatollahi, Mirani & Haghani, 2014). However, intentional or unintentionally, nurses enter wrong data regarding patient information that is unsafe and breach of conduct. For example, the treatment cancer of a patient was delayed by many years because a piece of information was wrongly entered in the EHR system. The system defaulted to an old test of Pap smear instead of the most recent abnormal findings. As the result of delayed diagnosis and treatment, patient life was endangered.
The ethical implication in this example is the breaching of beneficence and non-maleficence. Healthcare professionals have the obligation to promote greater good for the patients and intentionally should not harm them (Grace, 2017). In the given example, due to negligence or breach of duty, wrong entry about patient lab findings resulted in hampering patient life and safety. According to ANA, under Provision 3, nurses have the responsibility to advocate and protect patient’s health, rights and safety (Taitsman, Grimm & Agrawal, 2013). They should create an ethical environment and have an affirmative duty to protect and prevent harm. There is breaching of patient actual data raising ethical implications of privacy and security. This example also depicts that it is the ethical responsibility of nurses to make proper patient information as it meet the needs of the patient. It also acts as an efficient communication tool that creates and ensures continuity in safe delivery and quality of healthcare.
During my placement at the geriatric ward in a hospital, I was instructed to look after a patient who had underwent a surgery. After my shift, I instructed over the electronic patient record to the nurse who would be attending after me. When I returned to my duty, I noticed that structured data indicated one pill twice a day and free-text field showed two pills morning and one pill in the evening. This gave me an instinct that the data entered was wrong regarding the inconsistent drug dose and there was some missing information. The positive thing about that incident was that it noticed and escalated the issue at the right time and negative aspect was that the previous shift nurse made wrong entry about the medication hampering patient safety. It could have been improved if previous shift nurse would have made proper data entry regarding the patient medication dosage breaching the ethical code of conduct of non-maleficence and beneficence.
From the above discussion, it can be concluded that data integrity in healthcare is an important aspect regarding patient information. Discrepancies in data protection pose ethical and legal implications like respect for autonomy, beneficence and non-maleficence, privacy and confidentiality. There is a responsibility to protect data as it is of extreme importance in healthcare as it is used to identify, track patients when they move from one care level to another. It hampers patient safety, pose harm and endanger quality of care provided by the patient. Among the healthcare workforce, nurses have the ethical responsibility to oblige to the ethical code of conduct and ensure patient safety and integrity.
References
Ayatollahi, H., Mirani, N., & Haghani, H. (2014). Electronic health records: what are the most important barriers?. Perspectives in health information management, 11(Fall). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4272437/
Fowler, M. D., & Davis, A. J. (2013). Ethical issues occurring within nursing education. Nursing ethics, 20(2), 126-141. Doi: https://doi.org/10.1177/0969733012474290
Grace, P. J. (2017). Nursing ethics and professional responsibility in advanced practice. Jones & Bartlett Learning. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=1OQlDgAAQBAJ&oi=fnd&pg=PR1&dq=beneficence+and+nonmaleficence+nursing&ots=eMHCE7AAz8&sig=g-qysNENqMRSHd5EjjJDRBL30JA#v=onepage&q=beneficence%20and%20nonmaleficence%20nursing&f=false
Huffman, D. M., & Rittenmeyer, L. (2012). How professional nurses working in hospital environments experience moral distress: a systematic review. Critical Care Nursing Clinics, 24(1), 91-100. Doi: https://dx.doi.org/10.1016/j.ccell.2012.01.004
Johnstone, M. J. (2015). Bioethics: a nursing perspective. Elsevier Health Sciences. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=4dRQCgAAQBAJ&oi=fnd&pg=PP1&dq=Code+of+Ethics+for+Nurses,+American+Nurses+Association&ots=YEsJSWvKdg&sig=yo_bCHEq56L9Eos8wehCYhgbA#v=onepage&q=Code%20of%20Ethics%20for%20Nurses%2C%20American%20Nurses%20Association&f=false
Taitsman, J. K., Grimm, C. M., & Agrawal, S. (2013). Protecting patient privacy and data security. New England Journal of Medicine, 368(11), 977-979. Doi: 10.1056/NEJMp1215258
Winland-Brown, J., Lachman, V. D., & Swanson, E. O. C. (2015). The new code of ethics for nurses with interpretive statements. 2015: Practical clinical application, Part I. Medsurg Nursing, 24(4), 268-71.Retrieved from: https://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics-2015-Part-1.pdf
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