This paper aims at creating a policy on how the manual medical health records will be converted into electronic health records. It also deals with implementation process as well as maintenance of the new electronic medical health records.
1. General Overview
With numerous technological advancements in information communication technology (ICT) and information systems (IS) over the past decades, particularly in medical health records, a number of healthcare institutions have developed and implemented electronic medical health records.
Generally, modern healthcare providers believe that adoption of electronic medical health records systems will result into decrease in cost of providing care services, and overall improvement on the quality of care services. Amatayakul (2010) stresses that the main goal of healthcare service providers in adopting electronic health records is to advance safety of patients, improve care services and efficiency. Lehmann (2011) and Amatayakul (2010) further assert that in most healthcare institutions, medical records are mostly stored on paper, thus hindering effective coordination of care services, improvement of quality of care services as well as organizational efforts to reduce informational errors relating to patients’ health.
Although many healthcare institutions have been shifting from manual medical health records to electronic medical health records, the pace of development and implementation of computerized patient healthcare information systems has not been very high. Not many healthcare institutions have successfully introduced electronic medical health records into their information systems. This has been pegged to various challenges and obstacles faced by healthcare institutions in their attempts to convert manual medical health records into electronic medical health records. Armoni (2009) lists high startup costs, lack of adequate technical expertise, stringent accreditation, certification and standardization requirement by healthcare informatics regulatory authorities, challenges of patient privacy and confidentiality and lack of proper coordination or interconnection between different healthcare providers and stakeholders as the major challenges facing organization that have attempted to adopt electronic medical health record systems. In addition, resistance by some healthcare professionals to replace manual documentation with electronic documentation has also been a major problem in most healthcare institutions.
Despite these challenges and obstacles, the interest to develop electronic medical health records has scaled up in many healthcare institutions. In this regard, Mercy Clinic also recognizes the importance and need to change from manual documentation system to electronic documentation system. Therefore, the organization would like to encourage its staff members to move from paper environment to paperless working environment. All departments and staff members are highly encouraged to support this noble move by the organization to shift from manual medical health records systems to electronic medical health records systems.
Mercy Clinic would also like to emphasize that the various challenges and problems experienced in maintaining manual health records are likely to be wiped out when the new electronic medical health records system will be fully implemented.
2. Policy Statement
Conversion of manual health records into electronic ones is a complex issue. Therefore, this policy paper aims at providing simple, precise and well defined guidelines and principles that will be applied during the conversion process.
3. Purpose of the Manual
This manual is intended to guide, help and facilitate medical health records workers in creating, developing and implementing an electronic medical health records system at Mercy Clinic. This manual offers guidelines on how to effectively convert the manual medical health records currently in use at Mercy Clinic into electronic medical health records effectively. It also provides guidelines on how to manage electronic medical health records in an effective and efficient manner. This manual has been written to smooth the process of conversion of manual medical records into electronic ones.This manual has been documented as a basic reference for use during the conversion of manual health records into electronic health records. It also provides a detailed description of appropriate procedures and practices for converting the manual medical health records into electronic medical records. It also provides a general view, some basic definitions, possible threats and challenges during the conversion process as well as the steps and activities during implementation processes. Particular focus has also been given to the maintenance of the new electronic medical health records. Various issues relating to the conversion process, development and implementation of the new electronic health records have also been addressed.
4. Scope of the Manual
This policy has been generated in line with the provisions and requirements of ISO TC 215 providing the international guidelines on technical specifications for electronic health records and ISO 18308 providing a detailed description for the architecture of electronic health records systems. In addition, this policy has adopted some concepts from SMART (Substitutable Medical Applications and Reusable Technologies) that provides an open platform specification to provide a standard base for healthcare applications.
This policy has also been developed in accordance with requirements of the Personally Controlled Electronic Health Record (PCEHR). The PCEHR is a national initiative by the Australian Government that aims at promoting an adoption of electronic health records systems by healthcare institutions within Australia.
Lastly, although this manual has been developed for use specifically by Mercy Clinic, it shall prove useful for use by other medical records departments of other hospitals as well as to healthcare providers.
5. Target Users of the manual
This manual has been designed for use by the following persons who shall be involved during the conversion process.
1. Health record officers and information systems administrators who are responsible for creation and maintenance of health records and health information within the institutions
2. The software developers and programmers who will be involved in creation of new software, programs and application to be used during the conversion process
3. Chief Information Security Officer who will be responsible for ensuring that various security issues relating to the newly created electronic health records is maintained
4. Management information systems specialists who shall be responsible for creating information databases for the electronic health records to be used by various healthcare professionals
5. Nurses, doctors, pharmacists and other healthcare professional who will be using the new created electronic health records while offering their services to patients
6. Any other person who requires in-depth knowledge and skills on usage of electronic health records.
6. Using the Manual
It is important for the reader to acknowledge that this manual does not provide a comprehensive step by step procedure for the actual conversion process, but it acts as a guideline to help during the conversion process. For a more detailed description of the step by step procedure on the conversion process, kindly refer to the actual Conversion Manual and Plan.
7. Electronic Medical Health Records
i. Definition of Manual and Electronic Medical Health Records
A medical health record refers to an account created and compiled by physicians, nurses and other healthcare professionals about the medical history of a patient. A medical health record contains information such as previous illnesses, present illnesses, medical examinations findings and previous treatments details. According to Amatayakul (2010), a medical record should also contain information relating to the response by the patients to medications, for example, development of side effects or hyper reactions to certain types of medicines. Medical records are kept for all patients regardless of whether they are in-patients or outpatients.
Medical health records can either be manual or electronic. A manual medical health record is a compilation of the information about a patient or group of patients that are recorded in paper and stored in files. On the other hand, electronic medical health records are complied information regarding patients that are recorded and stored within electronic systems such as computer systems.
ii. Drawbacks of Manual Health Records
Manual health records may allow the patient to access sensitive information. Hebda, Czar and Mascara (2011) define sensitive information as any information that is considered crucial to decision making or that is personal and private. An example of crucial information is information about the HIV status of patient. Such information should not be released to any person such as a brother without informed consent of the patient.
iii. Electronic Medical Records
An electronic health record is a systematic collection of health information about a patient in a computer system. The health information about patients is usually stored in digital formats, thus facilitating sharing of such information across various healthcare settings. Sharing of electronic health records usually occurs through computer systems and networks.
iv. Advantages of Electronic Medical Records
Electronic health records contain a variety of information such as medical history, results from laboratory tests, medications, responses to medications by patients, allergies, personal information of the patients such as age, place of residence, occupation, weight and height. In addition, electronic medical records also show the billing systems for patients. Electronic health records contain a huge range of information that could not be otherwise stored in manual records. According to Pharow and Blobel (2008), electronic health records have been proved to be able to improve the quality of healthcare services. The main reason for adopting an electronic medical health record system is to help in reducing the cost of providing healthcare services. A research study by Amatayakul (2010) revealed that adoption of electronic health records by large institutions helped in reducing operational costs by nearly twelve percent. Mercy Clinic believes that introduction of electronic medical health records will save nearly two million U.S dollars annually by reducing the cost of handling and distributing data.
Although Pharow and Blobel (2008) argues that most patients have reported that their privacy is at risk due to ease of sharing of information stored in electronic records systems by healthcare professionals, the benefits of using electronic health records greatly surpass the disadvantages that may be generated.
v. Reasons for adoption of Electronic Health Records at Mercy Clinic
Mercy Clinic supposes that the adoption of electronic medical health records system will assist the organization in attaining long-term preservation and storage of health information. According to Gartee (2007), data stored in electronic form can live for a period of twenty to one hundred and fifty years. This makes electronic systems the most suitable for storing data for large organizations that value business continuity.
Moreover, the electronic health records will also facilitate merging of healthcare information databases, hence improve provision of healthcare services. Electronic health records will also help in provision of e-health services to patients who may not be able to physically access healthcare facilities.
Skolnik (2011) also urges that electronic records facilitate exchange and sharing of clinical information relating to patients amongst healthcare service providers and government authorities and agencies. This helps in improving national healthcare services.
8. Review of how manual medical health records are currently created and maintained and the security threats they are exposed to
At the moment, manual medical health records at Mercy Clinic are created by physical recording of patient information on patient files. Data relating to medical history of patients are captured in visitation cards after which they are transferred to the patients’ files. These files are then stored in safe wardrobes and cabinets found within the department of Medical Records and Patient Information.
Various security issues usually emerge in relation to patient information stored in the manual medical health records. For example, these files can be accessed by unauthorized persons, hence leading to breach of patients’ privacy and confidentiality. In addition, the files can be easily misplaced thereby resulting into loss of vital information relating to the history of health of patients. The manual records are also pored to destruction by natural disasters such as rain, fire and dust.
9. Review of how the Patient Information System (PAS) works with the use of Manual Medical Health Records
At the moment, the Patient Information System involves physical recording and storage of data. All information captured in the visitation cards for patients are transferred to patients’ files and then safely stored. In the patient information system, each patient is given a unique number which is used to identify him or her. This unique number is written on both the visitation card as well as on the outer surface of the patient’s file. Any patient who comes for a second visit must quote his or her unique number awarded to him or her during a previous visit. This helps to ensure continuity of information stored within the manual records about a patient.
10. Information Flow in the new Electronic Health Records System
The flow of information in the new electronic health records systems will be the same as the one for manual records system except that data into the system will be entered by healthcare professionals at the point of care. In addition, data shall be transmitted across the systems via computer networks and electronic devices. A structure format shall be used during data entry into the systems to ensure safety and security of patient information.
11. Preliminary Steps in Converting Manual Health Records to Electronic Health Records
a) Formation of a steering committee
The first step in converting the manual health records into electronic health records is to form a steering committee that will oversee the entire process. The steering committee will be known as Committee for Implementation of Electronic Medical Health Records. The members of this committee must have adequate technical expertise on development of electronic health records or creation of management information systems in addition to basic computing skills. Moreover, all members of the committee must have indubitable understanding and background on management of both manual and electronic health records systems. The committee shall consists of members drawn from various departments such as the administration department, information technology (IT) department, health information and records management department, physicians and other potential users of the new health records. The main goal of including potential users of the new electronic health records system is to help in identification of various needs of the system users, hence facilitate development of specific features that will meet such user needs.
b) Review of existing manual health records
This forms the second stage in converting manual health records into electronic health records. The Committee for Implementation of Electronic Medical Health Records will be tasked with a detailed review of exiting manual health records to assess their functionality, quality, cost of management and challenges faced in using the manual records. During the review process, all problems and issues that may emerge as a result of the change must also be fully addressed. In addition, the committee will also prepare a detailed report that outlines the perceived benefits that are likely to accrue to the organization as well users of the new electronic medical health records.
c) Planning for the introduction of the electronic health records
At this stage, the decision to go ahead with the development and implementation of the new electronic health records will have been made. In addition, all challenges and issues relating to introduction of the new record systems will have been identified. The planning stage also involves seeking reviews and comments from the potential users of the new electronic medical health records to determine their user needs. In addition, the planning stage encompasses setting a timeframe for implementing the change.
d) Development of Electronic Medical Health Records
This is the most crucial step during the conversion process. It involves creation of databases for storing data and information relating to patients within the new system. This stage can be further divided into two main processes, namely installation of software, programs and applications, data recording and entry.
Policies and Guidelines on Development of Electronic Medical Health Records
1. All employees of Mercy Clinic must be pre-informed about the intention of Mercy Clinic to adopt a new health record system
2. Developers of software, programs and applications for the electronic records system must first review the current manual system
3. All software, program and applications developed for the new electronic records system must meet set organizational standards for health information systems
4. The new electronic health record systems must be able to efficiently accommodate and capture all data in the manual health records
i) Installation of software, programs and applications
This stage involves identification, acquisition and installation of relevant software, programs and applications that are to be used with the new electronic medical health records system. Selection of a software or program to be installed shall depend on its cost, usability, compatibility with existing information systems and maintenance costs. It addition, the software, program or application chosen should be able to facilitate easy entry, storage and retrieval of electronic data and information from the system.
ii) Patient Identification
One of the major goals of the electronic health records system is to identify every patient uniquely. This will involve use of a Unique Patient Identifier Code (UPIC) that shall be distinctive to every patient. A Unique Patient Identifier Code shall store information relating to the patient such as medical number, names of the patients, sex, date of birth, address and other relevant information that will assist in identifying a patient.
iii) Coding of Patient Information
Coding of patient information into the new electronic health record systems shall be conducted as per the standards and guidelines of Health Level 7 (HL7). HL7 is an international accreditation organization that provides standards and guidelines for coding and storage of health data electronically. Mercy Clinic believes that coding the health information as per the HL7 standards will improve the integration of various applications used in the electronic health records system.
iv) Data recording and entry
This is where actual data shall be entered into the new electronic health records systems from the old manual health records systems. Data entry shall be done by the Medical Record Officers with assistance from the data entry clerks. Data recording and entry activities shall be supervised by the Chief Medical Health Information and Records Officer.
v) Type of information to be captured by the electronic health records systems
The following list shows various information to be captured by the new electronic medical health records system.
a) Contact information of the patients
b) Age and sex of patient
c) Information about previous visits to Mercy Clinic
d) Personal allergies and history of negative reactivity on certain types of drugs
e) Family history
f) List of previous and present medications
h) Place of residence
i) Records on past hospitalization
j) Information about diagnosis, laboratory test results and treatments provided
k) Information about any surgeries or procedures performed
l) Health Insurance information
m) Immunization status
n) Any other relevant information pertaining to the health of a patient
e) Education and training
This will involve thorough training of all users of the new electronic health records. According to Amatayakul (2010), adequate training and education of staff member when a change is introduced within the organization helps in reducing resistance to change.
The implementation process will also involve creation of a graphical interface user that is known as the Computerized Patient Record System (CPRS) that would allow health care providers to examine and renew electronic medical record of patients at any department of Mercy Clinic. Another program dubbed the Health Data Repository (HDR) will be created to allow for sharing of patient records between various departments in the organization.
In addition, the program called Mercy Clinic Connect shall be created to ensure that the newly created electronic health record systems is compatible with manual health records systems as well as other information systems already in use at the institution.
i) Type of implementation process to be used
In order to effectively and efficiently achieve the conversion process from the manual medical health records to electronic medical health records, Mercy Clinic will deploy phase implementation method.
ii) Phase implementation
This is whereby the conversion shall be conducted in phases or units. It shall be achieved through the help of a pilot program that would determine the capability and readiness of the organization for the new electronic health records systems. In phase implementation, data from the old manual records systems will be introduced into the new electronic records systems in small scales.
Mercy Clinic has chosen phase implementation because it will ensure that users of the electronic medical health records are familiar with the new changes before fully program implementing.
In addition, phase implementation is easier to control and follow up, thus making the conversion process less risky. Phase implementation also gives adequate time for assessing and evaluating the operational ability of the new electronic medical health records system, hence adjustments can be easily made.
Walker, Bieber and Richards (2010) also urge that phase implementation usually provides users of a newly implemented systems with adequate time to adapt to changes, hence reducing employee resistance and other possible difficulties that users may experience due to change introduction within the organization.
iii) Policies on Integration of data from manual health records into the electronic health records
1. All old data in the manual health records shall be scanned and made part of the new electronic records system
2. All data from the old manual records systems must be pre-tested and confirmed appropriate before use with the new electronic records system
3. Any data found incompatible with the electronic records system shall be safely stored for future use and reference
iv) Timeline for implementation
The timeline for implementation for the conversion process will be five months. The conversion shall be implemented in two phases. The first phase will take three months, two months for shifting and one month for post-implementation review. Upon successful completion of the first phase, the second phase will start in the fourth month and take another two months.
Each phase of implementation shall consist of pretesting of the systems, installation of software, programs and applications, users’ education and training and post-implementation review. Each activity in the implementation phase shall have specific timeline.
g) Post Implementation Review
This stage involves carrying out periodic assessments or reviews on the performance of the new electronic medical health records system upon its implementation. The assessment will aim at identifying possible drawbacks of the new electronic records system.
Policies for Post Implementation Review
1. All users must carry out regular check on the new system to track its performance
2. Users must keep a track record of suspicious occurrences in the new system
3. System failures must be reported to the information officer or any relevant authority as soon as possible to facilitate formulation, development and implementation of corrective measures
4. All users of the new system must create and maintain well updated log book for tracking performances of the new electronic health records system.
12. Storage of Electronic Health Records
Appropriate strategies shall be developed to ensure adequate accessibility of the electronic health records. The primary storage facility will be a central processing unit (CPU) that will make patient information readily available to all departments and healthcare professionals within Mercy Clinic based on their needs for use.
In addition, secondary storage facilities including removable or external storage devices such as floppy disks and magnetic tapes shall also be used to store data. It is important to note that secondary storage facilities shall only be used for backup purposes.
Guidelines on Storage of Electronic Health Records
a) All electronic health records and system components must be stored in prescribed areas only such as the computer labs and health records offices
b) No unauthorized person shall be allowed to gain access to storage facilities where electronic medical records are kept
c) Non-health records officers visiting storage areas for electronic medical records shall only be allowed to do so in the presence of, and under strict escort by, the records officer
d) Maximum safety and security of stored electronic records must be ensured all the time.
13. Risk Management during the Conversion Process
Various risk management strategies shall be put in place to deal with anticipated challenges and barriers that might hinder smooth implementation and conversion from the manual health records system to the new electronic one.
Some of these strategies include:
a. Ensuring that there are adequate finances to facilitate acquisition of appropriate systems applications, software, hardware and other computing resources necessary for the conversion process.
b. Securing of ample skilled resources which include both human capital and technical resources.
c. Development of training and education materials for providing training services to potential users of the electronic health records.
14. Quality Assurance during the Conversion Process
As stated above, one of the major goals of converting manual health records into an electronic health records system is to improve the quality of healthcare services provided by Mercy Clinic. Generally, this will be achieved through improving the outcomes of the healthcare services and proper management of patient information.
Policy Guidelines for Quality Assurance
In order to ensure high quality assurance standards, the following guidelines should be observed.
a) All users of the new electronic heath records systems must use information found within the system in proper and suitable manner
b) All users of the electronic health records system must observe ethical and professional practices when using the system. This is to ensure that information found in the system is used for the organization benefits.
c) All users of the electronic health records system must perform regular audits to verify authenticity of the information in relating to decision making process.
d) All users of the electronic health records system must deploy appropriate utilization patterns that make it possible provide better healthcare services.
15. Components of the Electronic Medical Health Records
The proposed electronic health records will consist of:
1. All personal health information about a patient. This information will be entered electronically by a healthcare provider at the point of care throughout the lifetime of the patient.
2. Well organized formats of health information about all patients.
3. System software, programs and application responsible for recording, storage and retrieval of data across the systems and across other information systems within Mercy Clinic.
16. Security issues with use of Manual Medical Health Records
a) Privacy concerns
Mercy Clinic recognizes that privacy concerns relating to information of patients apply to both manual and electronic health records. One of the greatest challenges to storing information in large data warehouses is security of such information. Health information that is exchanged through the internet is subjected to various security concerns. More security threats include human activities such as non-loyal employees and hackers who use stored data for malicious purposes, threats for nature and the environment such as fires and earthquakes and technological challenges such as failure of computer and information systems, software malfunctioning and hardware destruction.
b) Protection of electronic health records
Threats to electronic health records can be categorized into four major groups namely internal, external, intentional and unintentional. This policy aims at establishing the rules and regulations on usage, disclosure and recording of patient information into the electronic health records systems.
In order to ensure maximum security for data stored in the electronic health record systems, two main approaches shall be used. Firstly, all information exchanged through information systems and networks shall have a standardized format. Secondly, development and implementation of security and privacy practices within the organization. The organization shall have stringent privacy policies and procedures to ensure protection of information stored in the electronic health records.
17. Change Management in Regards to Conversion of Manual Health Records to Electronic Health Records
As stated above, there are numerous challenges in conversion of manual medical health records into electronic ones within an organization. Therefore, it is important for Mercy Clinic to adopt appropriate strategies and procedures that will ensure that these challenges are dealt with effectively and unforeseen risks and obstacles that are likely to be faced by Mercy Clinic are minimized. This calls for effective change management by the organization during the conversion process.
The following strategies and procedures shall be observed.
· Development of goals and objectives for the conversion process as well as communication the foreseen benefits and value that the new electronic records systems will add in the organization to all potentials users and employees.
· Empowering employees of Mercy Clinic to fully embrace the change
· Potential barriers to effective implementation of the conversion process should be identified as early as possible and appropriate countermeasures taken. Some of the potential barriers include low levels of computer skills amongst employees, inadequate resources including technical and human and poor earning culture within the organization that does not embrace change.
· Creation of a supportive culture in the organization. The management should always provide adequate support to junior employees.
· Advocating for team work and team spirit within the organization.
· Creation of a conducive environment that encourage success
· Proper training and education of all potential users of the new electronic medical health records systems. This will help in creating awareness and familiarity amongst the users.
· Good leadership and effective communication amongst all participants involved in the conversion process.
Mercy Clinic would like to emphasize that effective change management is important in ensuring that the conversion process is successfully implemented with minimal barriers. In summary, the change management will be a three-pillar process consisting of management of people, the conversion process and technology as shown in the diagram below.
18. Ensuring Security during the Conversion Process and Prevention of Data Process Errors
During the conversion process, two major issues must be considered to ensure maximum security of data. Firstly, data should be protected from unauthorized access, manipulations and alterations. In order to prevent unauthorized access of data, only authorized personnel will be allowed to gain access to both manual and electronic medical health records systems. Every authorized user of data stored in both the manual and electronic medical health records systems shall be held accountable for any mistake that may occur when they handle data within the two systems.
Moreover, the number of unsuccessful log in attempts will be limited to three during the conversion period to ensure that no authorized person accesses the electronic medical health records system.
Secondly, data should be protected from errors likely to be caused by authorized users such as medical records officer and data entry clerks. Errors resulting from authorized persons shall be controlled by advocating for high levels of accuracy during data handling.
In addition, the strategies and mechanics for ensuring data security will vary in accordance to the sensitivity of the data as well as the level of implementation process for converting data from manual to electronic system. Stringent measures shall be taken to ensure that highly sensitive and confidential information is given adequate protection. Some of the data protection mechanisms to be deployed include authentication and authorization as well as use of log in accounts with secure passwords.
In addition, the new electronic medical health records systems will have an automated security mechanism to provide more security to information stored within the computer system. During the conversion process, various consistent procedures shall also be ensured to allow smooth transition from old manual system to the new electronic one.
During the conversion process, data entry and change shall only be performed by authorized persons. They are: the medical records officer and chief information systems officer. Moreover, an error correction shall only be done by the medical records officer and chief information officer to ensure that unnecessary manipulations of the data contained within the new electronic records system are not done. All data entered the new systems must be validated by the medical records officer. All changes in data within the systems should also be documented.
a) Polices Guidelines for Protection of Data during the Conversion Process
The following policies, guidelines and principles must be observed by the aforementioned parties in order to ensure adequate protection of data during the conversion process.
Policies for Data Entry Clerks and Data Officers
1. Each data entry clerk or data officer must complete Mercy Clinic’s security awareness training course and agree to uphold all rules, guidelines and requirements of this policy
2. Any data entry clerk, data officer or employee of Mercy Clinic who identifies an unauthorized person within the medical records offices or department must report such as person to the security personnel.
3. No visitor shall be allowed in the medical records office during the conversion period. Any person authorized to visit the medical records department during this period shall be required to be under strict escort by a record officer to ensure that such a person do not tamper with any of medical record or information.
4. All data entry clerks and data officers must keep their working desk clean all the time to prevent unnecessary exposure of medical records or health information
5. Any information being transmitted from manual records to electronic records system during the conversion must be encrypted accordingly.
6. Data entry clerks and records officers must notify the chief information security officer any loss of data or device containing data
7. All employees responsible for handling of data during the conversion period must ensure that portable computers and external storage devices that contain data are not unduly exposed.
8. If any malfunctioning of the new electronic records systems is detected, such occurrence must be reported to the chief information security officer immediately.
9. All workers responsible for transfer of data from the old manual system to the new electronic system must ensure that no data leakage occurs during the conversion process
10. Finally yet importantly, appropriate technical and organizational measures relating to protection of data against unauthorized and unlawful access must be strictly observed.
b) Using and Implementing Electronic Templates
Electronic templates shall be created and maintained at the system to provide guidelines on how to use the new electronic health records system. These templates shall be made available to all potential users with or without user accounts. In addition, hard copies of the templates and user guidelines can also be obtained at the health information and records offices located at the New Administration Block, 2nd floor, Room 5 (Note: This is a fictional geographical location for illustration purposes only).
c) Handling of Software Problems
Any problem that may arise due to incompatibility of software and hardware should be reported immediately to the information technology and communications (ICT) officer. Upon receipt of the incompatible software, the ICT Officer will take necessary actions which may include returning the software back to the vender.
d) Recommendations for ensuring no loss of data when converting Manual Health Records to Electronic Health records
In order to ensure that there is no loss of data during the conversion process, all data from the manual health records shall be handled by authorized persons only. Such persons must have adequate computing skills and knowledge on management of health information and medical records.
Similarly, all manual records shall not be destroyed until full implementation of the entire conversion process. Copies of data stored in the manual health records shall be retained by the organization for future reference purposes.
Appropriate software, programs and applications must be installed into the new electronic system prior to transfer of data from the old manual records systems. In addition, relevant changes must also be made in the operating systems of the new system to be able to accommodate all the data obtained from manual health records.
e) Recommendations on keeping Hard Copies of all Electronic Health Records
Hard copies of all electronic health records shall also be kept in safe and secure file cabinets where they cannot be accessed or destroyed by unauthorized person. These hard copies shall be used for reference purposes from time to time or incase a discrepancy in the information contained in the new electronic records system arises.
f) Policy on introduction and usage of electronic devices to access information in the new Electronic Medical Records system
Use of electronic devices such as external storage devices like floppy disks and flash disks shall not be allowed, unless an authority form the medical records officer or chief information security officer has bee obtained; such electronic devices may contain malicious programs such as viruses that may destroy data stored in the electronic health records systems.
Ipads, Palmtops and tablets can only be connected to the electronic health records system upon authorization by the medical records office or the chief information security officer. In addition, after receiving authority to connect any electronic device to the electronic health records systems, the user must thoroughly scan the devices or devices by an active antivirus and delete any virus detected. This will ensure that information in the electronic health records system is not tampered with.
g) Use of Ipads, Palmtops and Tablets to input new information into the Electronic Medical Records by Doctors and Nurses
Doctors and nurses will be allowed to connect their Palmtops and Tablets to the new electronic health records system only after approval by the medical records officer or the chief information security officer.
Upon connection to the electronic system, doctors and nurses are allowed to input new information to electronic system without manipulation any existing data. Moreover, irrelevant files such as media files shall not be allowed into the computing systems of the organization.
19. Manual for accessing and using information stored in the Electronic Medical Records system
The following procedures outline how information stored in the electronic medical health records system shall be accessed.
Step I: Visit the home page of the organization at http://www.mercyclinic.org/e-records. (Note: this is a fictional link for illustration purposes only).
Step II: Log in using your user name and password. If you are a new user, click ‘Create new Account’. Note: Only doctors, nurses, medical records officers and data entry clerks in the health record and information department will be able to create their own accounts, other users should seek assistance form the medical records officer or the chief information security officer.
Step III: Click on ‘Update Patient Information’ to add health information relating to a patient.
Step IV: Click ‘Save’ to save the changes.
Step V: Click ‘Log off’ to exit the system.
All users of the electronic records system must ensure that they log out of the system to ensure that no unauthorized persons access the system using their accounts. In addition, no authorized user is allowed to share his or her username and password with any person, unless authorized to do so by the medical record officer or chief information security officer.
20. Precaution on Usage of Electronic Health Records
Unlike manual health records, electronic health records can be created, used and edited by multiple independent entities. This poses great risk to such information, hence the need to ensure maximum security for such information.
This policy also recognizes that the startup cost for converting manual health records into electronic heath records and the maintenance cost for sustain the electronic health records, cost of training medical health record officers and other user of the systems might too high. However, this organization would like to asset that in the long run, the cost shall gradually decrease, hence more benefits will accrue.
21. Anticipated benefits of using the new Electronic Medical Health Records
1) Electronic health records will facilitate automatic sharing of information amongst various department and users within Mercy Clinic
2) Creation of efficient and effective storage and retrieval facilities for health information
3) Provision of a universal platform that standardizes healthcare services within Mercy Clinic
4) Facilitate decision making processes when information in the system are linked with Decision Support System (DSS) and Expert Systems (ES) of the organization
5) Low cost of handling data.
One attribute of developing and implementing electronic health records in an organization is to create an organizational wide information network that would facilitate sharing of health information within the institution. Electronic health records also facilitate availability of health information all the time anywhere, hence facilitating decision making processes amongst healthcare service providers. The shift from manual to electronic often poses numerous challenges to implementing organizations. With this in mind, Mercy Clinic believes that this policy will be useful during the conversion process from manual health records to electronic health records.