Concepts of Health Information Systems

 

                                                            Introduction  

A new hospital is opening in Ferndale and I am hired to be in charge of the health information management systems and electronic health records (EHRs). It is my responsibility to come up with a comprehensive health information system to facilitate the provision of better health care services. In this paper, I will discuss the significant elements that an HIS will need in order to address an efficient and successful health information system. These elements include the use and content of EHRs, documentation guidelines, and the security of EHRs.

Uses of the EHR – Patient Care, Administrative, Billing, and Research

Patient Care

            Patient care is one of the most important uses of EHRs. The use of an EHR is beneficial to patient care because it can help reduce mistakes, enhance the safety of patients, and improve patient outcomes (Miller et al., 2016). As much as electronic health records are concerned, research indicates that they have the potential of enhancing patient care, foster performance measurement in experimental practice, as well as facilitate medical related research. As a means of improving patient care, it should be understood that EHR do not contain clinical or treatment histories of patient. It is mainly built for the purpose of storing clinical data gathered by the healthcare provider’s office. As evidence based tool, it will be offering physicians with an easy way of making decisions regarding the patient care. In the process of enabling the physicians to reduce therapeutic mistakes, it streamlines workflow, as well as enhances the safety of the patients (Cavalieri et al., 2015).

Administrative

            The EHR always will give the hospital the potential of storing and providing essential clinical data regarding a person’s care under a certain healthcare provider. These data consists of signs and symptoms, progress notes, past clinical history, demographics, prescriptions, laboratory information, and other associated problems. As a means of streamlining workflow, it also has the potential of supporting healthcare-related activities which in return strengthens the patient and clinician relationship (Schacknow & Samples, 2010). 

Billing

            With the electronic health record (EHR) systems in place, it implies that it will have the potential of improving the clinical practice management through cost savings and increasing practice efficiencies. Additionally, as much as billing is concerned, it will also benefit the clinical practices through reducing transcription expenses, decrease storage, chart pull, and re-filling, expenses which in return aid in improving automated coding and documentation capabilities. This will also improve the health of the patient through patient education and efficient disease management (Hlatky, 2013). 

Research

            Advancing this technique to randomized therapeutic trials, it will be possible to use the EHRs to facilitate patient recruitments, assess study feasibilities, as well as streamline the collection of information at the baselines and follow-up.  As a means of maintain privacy and security to healthcare information, it will be important to ensure that the challenges that are brought about through interlinking diverse systems and infrastructure maintenance have been addressed.  Similarly, a step will have to be taken towards collaborating with regulatory organizations, HER vendors, policy makers, healthcare industry, and the patients to facilitate greater use of this system (Cavalieri et al., 2015).

 

Content of the EHR – Patient Information, Demographics, and Consent         

Patient information

            An EHR contains the following patient information; medical histories, diagnoses, medications and allergies, date of immunizations, vital signs, progress notes, lab and test results, and administrative and billing data. All of this information is stored into a digital record, which can be shared amongst other providers and organizations that are involved in the patient’s care.

Demographics

            An EHR also contains patient demographics, including age, marital status, sex, preferred language, employment, race or ethnicity, and insurance. Patient demographics must be included in an EHR because they provide details identifying who the patient is. These features can also help physicians with determining their top differential diagnoses since some diseases are more commonly seen in specific demographics.

Consents

            In an EHR, consent gives staff members permission to share and access patient’s health information through a Health Information Exchange (HIE) for treatment, payment, and health care operation purposes (Lennon et al., 2017).

                                      Documentation Guidelines of EHR

            The operation management team takes the responsibility of documenting patients’ past and present clinical healthcare records through the use of a useful coding compliance program. In order to be in the position of accessing the effectiveness of the program during documentation, this team will have the duty of measuring various outcome indicators. There is also the need of using the contractor initiated program to aid in monitoring documentation requirements (Tharpe, 2016). 

                                                Ensuring compliance with HIPAA

            To ensure compliance with HIPAA, I will distribute the policies on privacy and security across the entire hospital setting for all staff members and assure that each member comprehends the privacy and security legal obligations. I will also talk to the staff about my expectations and clarify the importance that all information regarding the patient is kept safe and protected. I will also perform a risk analysis to put into the record the possible threats and any weaknesses that can be exploited to ensure the protection of personal information, integrity, and the accessibility of PHI for patients who were or are in our care.

            On the other hand, the privacy and security of the patients’ information is one of the issues that ought to be given greater consideration. Therefore, the general access to the hospital or the patients’ health information should only be done with after being permitted. As a means of monitoring compliance with authentication, it is vital to ascertain whether prominent security techniques have been put in place so as to ensure that the safety of the EHR. Moreover, there will be the need of ensuring that those within the department have read and understood the security safeguards that are contained in the HIPAA (health insurance portability and accountability act and in HITECH ( health information technology for economic and clinical health act). All that will take into account the technical, physical, and administrative safeguards provided by these acts (IGI Global & In Information Resources Management Association, 2018). 

Ensuring that data is secured

            To ensure that data is secured from internal and external threats including: intentional hacking, human errors, natural disasters, and equipment or software failures, I will provide a security system where only authorized individuals can gain access to information. As much as the protection of the patients and the organization’s information is concerned, one of the strategies that can be used to permit that is the use of firewalls. Regardless of the fact that this method can be costly, it has been proven to have the potential of securing the hospital’s network which in return protects the health care information that reside within the network. Depending on the scope and the needs of the organization, it possible to use any of the following firewalls, including packet filtering, status inspection, application level, or the net address translator. Another method that can be recommended is the use of digital signatures to prevent breaches whenever patients decide to view their information (Nass et al., 2009). 

            Nonetheless, it is important to use passwords and usernames that can aid in preventing breaches through the incorporation personal privacy. Passwords will have to include dates or names that can deter the hacker from speculating them. The passwords would be needed to be changed defined intervals where the reuse of a password is restricted, and the password is unique within a minimum number of characters (Sittig & Singh, 2015). I will ensure the authorization is based on a two-tier approach and managed through biometric identifiers such as scan of retina, finger, palm, or face recognition. The use of the two can also enable the health care providers to establish role-based access controls. It is also important to remember logging out from the system to avoid leaving organizational or patients PHI (protected health information) to unauthorized people (Nass et al., 2009). 

 

                                                           

 

 

 

 

 

                                                            References

Cavalieri, R. J., Rupp, M. E., & Sigma Theta Tau International,. (2015). Business administration for clinical trials: Managing research, strategy, finance, regulation, and quality.

Hlatky, M. (2013). Comparative-Effectiveness Research in Heart Failure, An Issue of Heart Failure Clinics, E-Book.

IGI Global,, & In Information Resources Management Association,. (2018). Censorship, surveillance, and privacy: Concepts, methodologies, tools, and applications. Hershey, Pennsylvania Ptress

Nass, S. J., Levit, L. A., Gostin, L. O., & Institute of Medicine (U.S.). (2009). Beyond the HIPAA privacy rule: Enhancing privacy, improving health through research. Washington, D.C: National Academies Press.

Schacknow, P. N., & Samples, J. R. (2010). The glaucoma book: A practical, evidence-based approach to patient care. New York: Springer.

Tharpe, N. L. (2016). Clinical Practice Guidelines for Midwifery and Women's Health. Jones & Bartlett Learning, LLC.