ELECTRONIC HEALTH RECORD

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5/2/12

An is an electronic version of a patients medical history. It is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider. These includes the following:

Electronic Health Record (EHR)

demographics, notes,

progress 5/2/12

The EHR automates access to information and has the potential to streamline the clinician's workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces:

including support,

evidence-based

decision

quality 5/2/12

management, and

EHR can improve patient care by:

Reducing the incidence of medical error by improving the accuracy and clarity of medical records. Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions. Reducing medical error by improving 5/2/12 the accuracy and clarity of medical

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Advantages :

no longer having to interpret poor penmanship and handwritten orders to reduce turn-around-time for lab results in an emergency department For prompt administration of the first dose of antibiotics in an inpatient nursing unit
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In the ambulatory care setting :

evidence of improved management of cardiac related risk factors in patients with diabetes effective patient notification of medication recalls

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Flexibility and Expandability

At a very basic level, there is as yet no electronic health record system available that can provide all functions for all specialties to a degree that all clinicians would successfully adopt. Most healthcare organizations do not yet have the capacity to implement and maintain systems 5/2/12

Patient privacy is a pivotal issue to determining how far and how easy it will be to share data across healthcare organizations. For health exchanges such as these to reach their full potential the public must be able to trust that their privacy will be protected, or else risk that 5/2/12 patients may not share a full

Concerns with EHRs

issue of privacy, confidentiality and protection of personal health information in the context of an EHR system is perhaps the most sensitive one raised

Currently, there is significant variation in privacy laws and data access policies across the country that poses a challenge for EHR systems that are 5/2/12

Privacy, Confidentiality & Security

Privacy: ones right to control who has access to information about oneself Confidentiality: a duty owed by one to preserve the secrets of another Security: mechanisms put in place to safeguard privacy and 5/2/12

Professional Duties

Hippocratic oath

Whatsoever I shall see or hear concerning the life of men, in my attendance on the sick, or even apart there from, which ought not to be noised abroad, I will keep silence thereon, counting such things to be as sacred secrets.

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Health Info Privacy Code

right of privacy fundamental in a free and democratic society includes patient's right to determine with whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her right of privacy and consent are essential to trust and integrity of the 5/2/12

Need for legal framework

EHRs potentially conflict with privacy principles unless patients control how the record is shared and appropriate security measures are in place. A coherent legal framework to appropriately protect the privacy and confidentiality of personal 5/2/12 health records is therefore an

Consent

Should individual consent be required before information is included in EHR or disclosed through EHR? To be legally valid, consent generally must be informed:

Who will have access to info? For what purposes? What security mechanisms are in place? What are risks of unauthorized access?

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Security Obligations

maintain administrative, technical and physical safeguards to protect confidentiality and privacy measures to guard against risks associated with EHRs audit logs privacy impact assessments
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Future

Nursing must stay engaged in this evolution and help shape its direction, as it has already proven to have a significant impact on our practice and our patients.

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Reflection:
1.

What are the implications for nursing education as the electronic health record (EHR) becomes the standard for caring for patients?

1.

What are the ethical considerations related to interoperability and a shared 5/2/12 electronic health record?