Implementing Electronic Health Records

Implementing an EHR can be a complex task to take on and planning the process is of utmost significance to lessen errors. Assessing the selection criteria and the plan for implementing an EHR , including availability, confidentiality, interoperability, and integrity of data, while ensuring compliance with regulatory and legal concerns is a critical task. The paper analyzes the implementation of electronic health records.Implementing Electronic Health Records

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Functional considerations to take into account when implementing an EHR

Usability, availability, and privacy and security are three functional considerations to take into account when implementing an EHR.  Usability is the extent to which an EHR support clinicians in accomplishing their goals in an efficient, effective, and satisfying manner. According to Sittig et al. (2018), the usability of an EHR is crucial to the improvement of quality of care and patient safety. Poor usability impacts the capacity of clinicians to complete tasks efficiently, effectively, and safely and is connected to high patient safety concerns. For instance, the majority of order-entry errors occur due to user interfaces that are hard to utilize or obscure vital patient information.Implementing Electronic Health Records

Poor system usability entailing wrong EHR design blocks face-to-face interaction with health care providers and patients forcing providers to spend more time to document needed health information for an HER. Features like cumbersome menus, pop-up reminders as well as the poor user interface have the potential of making an HER more time consuming compared to a paper records(Keshta & Odeh, 2020).

Privacy is the right that an individual has to determine for themselves how, when, and the extent to which their health information is shared or transferred by others. Security is the extent to which accessing an individual’s health data is restricted and permitted only for those authorized.  According to Keshta and Odeh (2020), breaching of privacy can occur in several circumstances via unavoidable systemic identification that takes place in the whole electronic health infrastructure and by central technologies as well as parties who access to the activities of patients and health care providers. Availability ensures that an EHR system is accessible and fully operational at any time that an authorized individual needs to use it. Availability implies numerous aspects from resilience to scalability and to recoverability of patient data in case the information gets lost (Keshta & Odeh, 2020).

Interoperability and why it is important

Interoperability is the standards or architecture that make it possible for diverse HER systems to exchange information between providers. Interoperable EHRs permit the electronic sharing of patient data between diverse HER systems and providers, improving the ease with which providers can offer care to their clients and the clients can move in different care facilities. Reisman (2017) indicates that interoperability is more than the capability to exchange patient health information.  For two EHRs systems to be interoperable, they must be capable of exchanging and then utilizing the data.  For this to happen, the transmitted message must have standardized coded data so that the system receiving the message can interpret it. Implementing Electronic Health Records

According to Sittig et al. (2020), flawless interoperability is fundamental to safe patient care since it is hard to make correct treatment or diagnostic decisions when there is no transfer and accurate incorporation of vital patient data into the coded segments of the EHRs utilized by different health systems.  Interoperability enables improved workflows and reduces vagueness and permits transfer and exchange of data among different EHR systems and health care providers. Also, interoperability improves health care delivery by ensuring the availability of accurate data to the right individuals at the right moment. With no reliable interoperability between EHRs duplicate tests can be performed on patients, which heightens the risk for patient harm.

Reliable interoperability between EHRs enables health care providers to check for allergies or other vital medical history and evaluate past laboratory or imaging results.  Also, safety might be compromised if one EHR system poor data management practices, for example, inaccurate or incomplete procedures for patient identification which compromises data integrity at other health systems through the creation of duplicate or patient records that are incorrectly merged (Sittig et al., 2020).

Regulatory considerations for implementing EHRs

Patients’ privacy and the security of patients’ health information are issues that should be considered when implementing an EHR. As a result of the sensitivity of the information stored in EHRs, the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Health Insurance Portability and Accountability Act (HIPPA) have introduced numerous security safeguards.  Kruse et al. (2017) allege that the security and confidentiality of protected health information (PHI), which is included in the EHR of a patient is addressed in the HIPPA. Security breaches violate patient privacy when confidential PHI is accessed by others without authorization or consent from the individual. Under HIPPA, patient information should be made available to others only when the permission of the patient or permitted by law.  The HITECH Act maintains a precise protocol that should be adhered to when reporting data breaches. An organization needs to understand methods for offering cyber-security that are connected with an EHR prior to its implementation (Kruse et al., 2017).Implementing Electronic Health Records

Data integrity and why it is important

An EHR system must be capable of enabling efficient availability of complete, correct,  and meaningful data to help improved clinical administration by developing, implementing, and optimizing clinical pathways. Thus, data integrity is vital to an effective EHR and is a fundamental aspect of the delivery of services at every level. Vimalachandran et al.(2018) indicate that data integrity is the reliability, internal quality, and accuracy of data. In an EHR, data integrity involves the accurateness of the complete documentation of health records. it includes governance of information, identification of patients and substantiation of authorship, and amendments of record. Additionally, the quality data in an EHR depends on correct information at the data source.

Data integrity is important because inaccurate health information might negatively affect the quality of healthcare of an individual. Dirty data which might include inaccurate, missing, or incomplete information can result in medical errors, which can cause harm to the patient’s health and even death. The quality of healthcare depends on the accuracy, reliability, and integrity of health information (Vimalachandran et al., 2018).

Why the security of data is important when implementing an EHR

The security of data is important when implementing an EHR to ensure that patient information is available to authorized users only. Keshta and Odeh (2020) explain that the information contained in an EHR is very sensitive, with the information including data related to patients’ diagnoses, treatment, and tests along with patients’ medical history.   Sharing or transferring sensitive patient information when not authorized can result in data breach.  It is thus imperative that this information is secured to prevent its manipulation and enable patients to go on sharing information concerning their health and ensure health providers are legally and ethically responsible (Keshta & Odeh, 2020).Implementing Electronic Health Records

The legal concerns surrounding the implementation of EHRs

An EHR has the potential to improve the quality of care and patient safety within a hospital. Nevertheless, there are significant legal issues that must be addressed prior to implementation. According to Palabindala et al. (2016), when planning to fully adopt an EHR system, an organization must identify and devote suitable ad medical and administrative staff to work on implanting the system, which entails devoted cooperation between the EHR vendor and the organization. Successful implementation of the EHRs system is dependent on a flawless transition from paper charting to electronic charting.

Poor implementation can increase the threat of error and subsequently expose hospitals and clinicians to possible medical malpractice lawsuits along with other legal complications. Providers have the responsibility of lessening risk during the transition stage. Palabindala et al. (2016) indicate that the HIPPA states that hospitals have the sole responsibility of their EHR system, entailing the way it is utilized.  As such, hospitals are required to understand these legal requirements when implementing an EHR.

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Conclusion

When implementing an EHR, numerous considerations should be put into account including usability and interoperability. The usability of an HER is vital to improving the quality of care and patient safety by enabling clinicians to complete tasks efficiently, effectively, and safely. Interoperability enables the exchange of patient health data among different EHR systems.  To be effective an EHR system must satisfy requirements such, be highly available, achieving complete data, and be compliant with security requirements.Implementing Electronic Health Records

References

Keshta, I., & Odeh, A. (2020). Security and privacy of electronic health records: Concerns and challenges. Egyptian Informatics Journal. https://doi.org/10.1016/j.eij.2020.07.003

Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2027). Security Techniques for the Electronic Health Records. Journal of Medical Systems, 41(8), 127. doi: 10.1007/s10916-017-0778-4

Palabindala, V., Pamarthy, A., & Jonnalagadda, N. R. (2016). Adoption of electronic health records and barriers. Journal of Community Hospital Internal Medicine Perspectives, 6, 5. https://doi.org/10.3402/jchimp.v6.32643

Reisman, M. (2017). EHRs: The Challenge of Making Electronic Data Usable and Interoperable. Pharmacy and Therapeutics, 42(9), 572-575.

Sittig, D. F., Belmont, E., & Singh, H. (2018). Improving the safety of health information technology requires shred responsibility: It is time we all step up. Healthcare (Amst), 16(1), 7-12. https://doi.org/10.1016/j.hjdsi.2017.06.004

Vimalachandran, P., Wang, H., Zhang, Y., Heyward, B., & Whittaker, F. (2018). Ensuring Data Integrity in Electronic Health Records: A quality Health Care Implication. https://arxiv.org/ftp/arxiv/papers/1802/1802.00577.pdf

Implementing Electronic Health Records