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Nursing Informatics

Task 1:

Introduction

An Electronic medical record system usually consists of computerized legal medical records created in an institution that delivers care, hospitals included. They almost have a propensity of being an autonomous health information system that allows the addition, process, manipulation, storage and retrieval of such records.

Fast, easy, accessible and single collation of medical records that the EMR system provides for either review or diagnostics of trends and genetically related health problems will benefit nurses in their work with patients and is important to the delivery of nursing care.

Patients divulge to their doctors very sensitive and private details about their emotional and health problems such as alcoholism and the abuse of drugs and even their sexual lifestyles. It is therefore presumed that such information is so confident that the physicians must keep and sustain their privacy.

Maintaining confidentiality is increasingly difficult in modem medicine. Several people can find in their possession a patient’s health records and this is not limited to just the doctor, others may be the house staff, medical assistants, students, social workers among many others (Siegler, 1982).

Although automated health records may improve accessibility to the records of patients, they also provide a more serious opportunity for the breach of such privacy. With EMR systems, confidentiality can be desecrated at one of the several stations that the system provides. This is because there is a lot of information one every convalescent and patient, and this data can be accessed not only for one patient but for several of them (NAP, 1997). Fax mails and electronic mail also have the potential of the potential of presenting such opportunities (Rind, Kohane and Szolovitis, 1997).

There are two HIPAA rules requirements; privacy (2003) and security (2005). Both rules require, identifying possible threats, assessing specific vulnerabilities, determining appropriate and reasonable safeguards and implementing the necessary defense mechanisms and policies.

Task 2:

Paper based records and systems necessitate a large amount of space for storage while on the other hand digital ones do not. All the costs, both financial and otherwise for such media that is paper and/or film given each single unit of the data that requires storing are at very dramatic variances. Whenever these records are stored in several places, to assemble or verify the information at one place for the purpose of review is not only complicated but consumes a lot of time, this process is quite simple when one is using an electronic system. This is true too for the instances when they have to be dispatched to several locations.

A study that was done in 2006 shows that electronic medical records have a six percent increase on the efficacy and efficiency of the operations of the health institutions and the costs of keeping the electronic system is offset by superfluous tests of admission. (Evans, Nichol, and Perlin, 2006). In addition, where the records are handwritten, there is always the problem of illegibility and consequently errors that may prove to be quite expensive to the hospital. On the other hand, digital data are capable of being continuous updating.

Given the capability of exchanging information across several and diverse systems facilitates the coordination of delivery of healthcare in other facilities that are not affiliated with health care. This data can also be used additionally for statistical reports in situation such as those seeking quality developments; the management of resources and the surveillance of diseases that may be contagious.

Active nursing involvement during the planning, choice, and implementation of the systems is important. This is because such a system is a workplace reality for most nurses. Apart from the advantages mentioned, it provides capacity for data interfaces and alerts; improved interdisciplinary communication; and evidence-based decision support. Therefore, a computerized system can add to work complexity, by forcing better documentation of previously unrecorded data and/or because of poor design and also streamline nurses’ work. It would therefore be counterproductive to introduce such a system then leave nurses out when making all the fundamental decisions.

In contrast to paper based records which require a significant amount of storage space, for instance in the US most of the states need them kept for a minimum of about 7 years; digital records are cheaper to store and could be easily accessed from a single storage.

Using an electronic medical record has no absolute right and wrongs in either computer equipment or software for HIPAA compliance. Usually there are four areas to examine physical security especially as to whether your computers with patient data could be stolen; user security as to whether anybody can log on to the patient database; system security such as when a hard drive crashes; network security such if there is a possibility for an unauthorized persons outside your facility accessing patient data.

Fast, easy, accessible and single collation of medical records that the EMR system provides for either review or diagnostics of trends and genetically related health problems will benefit nurses in their work with patients and is important to the delivery of nursing care. This is particularly true where the records are person centered, any other mode of storage would be almost impractical. Not to mention the other costs such as transporting, faxing or copying of paper based medical records which may be cumbersome and slow.

References

Committee on Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure (1997). For The Record: Protecting Electronic Health Information. Washington, DC: National Academy Press.

Rind, D. M., Kohane, I. S., Szolovitis, P. (1997). Maintaining The Confidentiality Of Medical Records Shared Over The Internet And The World Wide Web. Ann Intern Med. 127:138-141.

Siegler, M. (1982). Confidentiality in Medicine: A Decrepit Concept. N Engl J Me. 307:1518-1521.

Evans, D.C., Nichol, W. P., Perlin, J. B. (2006). Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration. Health Econ Policy Law 1 (Pt 2): 163–9.