Electronic Health Records: Privacy, Confidentiality, and Security

2012 Virtual Mentor  
Health Information Systems: Past and Present To understand the complexities of the emerging electronic health record system, it is helpful to know what the health information system has been, is now, and needs to become. The medical record, either paper-based or electronic, is a communication tool that supports clinical decision making, coordination of services, evaluation of the quality and efficacy of care, research, legal protection, education, and accreditation and regulatory processes. It
more » ... s the business record of the health care system, documented in the normal course of its activities. The documentation must be authenticated and, if it is handwritten, the entries must be legible. In the past, the medical record was a paper repository of information that was reviewed or used for clinical, research, administrative, and financial purposes. It was severely limited in terms of accessibility, available to only one user at a time. The paper-based record was updated manually, resulting in delays for record completion that lasted anywhere from 1 to 6 months or more. Most medical record departments were housed in institutions' basements because the weight of the paper precluded other locations. The physician was in control of the care and documentation processes and authorized the release of information. Patients rarely viewed their medical records. A second limitation of the paper-based medical record was the lack of security. Access was controlled by doors, locks, identification cards, and tedious sign-out procedures for authorized users. Unauthorized access to patient information triggered no alerts, nor was it known what information had been viewed. Today, the primary purpose of the documentation remains the same-support of patient care. Clinical documentation is often scanned into an electronic system immediately and is typically completed by the time the patient is discharged. Record completion times must meet accrediting and regulatory requirements. The electronic health record is interactive, and there are many stakeholders, reviewers, and users of the documentation. Because the government is increasingly involved with funding health care, agencies actively review documentation of care. The electronic health record (EHR) can be viewed by many users simultaneously and utilizes a host of information technology tools. Patients routinely review their electronic medical records and are keeping personal health records (PHR), which
doi:10.1001/virtualmentor.2012.14.9.stas1-1209 pmid:23351350 fatcat:bpx22m7wwzanxgsaleeemefgqu