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Patient Information Capture: Design and Principles

Patient Information Capture: Design and Principles


            Health information technology is an umbrella term that is used to denote the wide range of technologies and systems that are utilized within the healthcare system to capture, store, analyze, disseminate, and share vital patient information within hospitals and healthcare organizations as well as among healthcare providers and other outside stakeholders. Health information technologies and systems provides enhanced potential for the healthcare system to improve the quality and sustainability of patient care and improve clinical outcomes (Kruse, & Beane, 2018). As a result of these potential benefits of information technologies, healthcare organizations and providers are rapidly transitioning into the new digital era by adopting and implementing electronic health record systems to help in the accurate capture, storage, and sharing of vital patient information (Zeng, 2016). However, to attain maximum operational efficiencies and comply with federal, state, and local, laws, adequate protocols have to be put in place concerning the sharing and receiving of patient information with, and from, outside providers.

Executive Summary of Compliance Procedures and Practices

            The roles and benefits of health information technology, and electronic health records systems in particular, within the healthcare environment are well documented. The exchange of health information is critical as it allows patients, providers, and healthcare professionals to appropriately access electronic information in real-time and also securely share such information with other stakeholders so as to improve care coordination and the quality of care delivery as well as the clinical outcomes. However, as the sharing of information between different stakeholders continue, so has concerns regarding to the meaningful use of these systems to ensure that optimum operational effectiveness and efficiencies have been promoted. In addition, growing security concerns within the United States have necessitated increased regulation in the area of health information security and required security practices needed to attain positive and better outcomes (Kwon, & Johnson, 2013). Therefore, as a result of these concerns, it is important that healthcare organizations ensure that certain protocols and practices have been observed when sharing information so as to promote optimum operational effectiveness and compliance with applicable federal, state, and local laws.

            As a healthcare organization that is committed to quality care, we constantly have to share patient information such as lab results, x-rays, and other diagnostic information with other providers and particularly with a certain diagnostic center. Such information sharing fosters the provision of safer and more effective care that is tailored to the unique medical needs of the patients and also facilitates faster and informed decision making. However, before such information can be shared, the following protocols and practices have to be strictly complied with;

  1. The first important protocol is that the providers with whom health information is shared with should have adequate and effective technical infrastructures. The providers should have in place electronic health record systems that, from a technical perspective, has the capability to send, receive, and query information that is disseminated through such systems. In addition, the systems should also be equipped with adequate information resources and support to facilitate the attainment of electronic health records and electronic health exchange goals and objectives
  2. The providers should also demonstrate adequate workflow and organizational support. Before any information can be shared, the providers should demonstrate an effective grasp of both the clinical as well as the non-clinical workflow efficiencies and improvements that support health information exchange. In addition, a culture that prioritizes healthcare continuity, comprehensiveness, and coordination should be properly demonstrated
  3. The third important guideline is sufficient training and support. The providers should have an effective in-house, or outsourced, training and support function that ensures that all relevant personnel have been properly equipped to utilize electronic health record systems in an information sharing context. Also, the outside providers should showcase a management function that is supportive of health information sharing and electronic health records and motivated employees who are committed to champion end-user results
  4. Perhaps the most important protocol that should be adhered with is the privacy and security of the shared health information. The providers should demonstrate compliance with all administrative, technical, and physical privacy and security requirements as outlined by all applicable laws. These included federal laws such as the health Insurance Portability and Accountability Act (HIPPA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) as well as all other applicable local and states regulations. These laws play an instrumental role in facilitating the sharing of health information and granting permissions to patients and providers (Ramanathan, Schmit, Menon, & Fox, 2015).


critical appraisal

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  1. Finally, but not least, the providers should demonstrate software elegance in the form of an interoperable electronic health record system. It is important for providers to work with vendors to ensure that they have designed useful, user-friendly, customized, and usable health information exchange systems that are interoperable, can effectively integrate into current workflows, and have adequate technical assistance and support (Wu, & LaRue, 2017).

Current Trends in Patient Data Capture and Information Sharing, and their Impacts

As the healthcare landscape continues to be transformed and shaped by health information technologies and systems, a variety of new trends in data capture and information sharing are emerging. The first important trend that is on the rise is patient-generated health information. Usually, within the electronic health records environment, it is the providers who have the ownership of generating, capturing, and sharing health information. However, recently, there continues to be a move towards patient-generated health data. Electronic health record systems allow patients to create, record, and gather health information related to particular health concerns and decide on how such data will be shared and distributed to providers and other healthcare stakeholders (Nittas, Mutsch, Ehrler, & Puhan, 2017). Such data may include things such as health history, lifestyle choices, biometric data, symptoms and treatment history, glucose monitoring readings, and diet and exercise tracking among others.

The utilization of mobile technology and cloud computing are other important current trends in health information sharing. Mobile technology is transforming the manner in which patients, providers, and healthcare professionals today interact with healthcare data and information. As a result of the many benefits that mobile devices provide, they have become commonplace within the healthcare environment and are continuously being utilized to facilitate information exchange and access (Ventola, 2014). On the other hand, cloud computing is also on the rise as a tool for health information exchange and storage. Through cloud computing, users are provided with on-demand access to a shared pool of information technology resources thereby resulting in improved flexibilities and efficiencies as well as reduced costs of information storage and exchange (Gao, Thiebes, & Sunyaev, 2018).

Other current trends in healthcare information capture and sharing include the move towards meaningful use, interoperability, and data security. With the continued advancements of healthcare technologies, there is an increased need for newer and better approaches to ensure that the privacy and security of sensitive patient information have been maintained. Also, there I a move towards ensuring adequate interoperability to facilitate easy transportation and sharing of data among stakeholders. Meaningful use and information governance have also become commonplace within the healthcare systems, and in electronic health records in particular. All these trends in patient data capture and sharing continuously impact on organizations in terms of increased research to keep up with the trends, additional investments to procure latest technologies, and enhanced quality and safety of patient care.


Gao, F., Thiebes, S., & Sunyaev, A. (2018). Rethinking the Meaning of Cloud Computing for Health Care: A Taxonomic Perspective and Future Research Directions. Journal of Medical Internet Research, 20(7). e10041. DOI: 10.2196/10041

Kruse, C. S., & Beane, A. (2018). Health Information Technology Continues to Show Positive Effect on Medical Outcomes: Systematic Review. Journal of medical Internet research, 20(2), e41. doi:10.2196/jmir.8793

Kwon, J., & Johnson, M. E. (2012). Security practices and regulatory compliance in the healthcare industry. Journal of the American Medical Informatics Association: JAMIA, 20(1), 44-51.

Nittas, V., Mutsch, M., Ehrler, F., & Puhan, A. M., (2017). Electronic patient-generated health data to facilitate prevention and health promotion: a scoping review protocol. BMJ Journals, 8(8). 17-27.

Ramanathan, T., Schmit, C., Menon, A., & Fox, C. (2015). The role of law in supporting secondary uses of electronic health information. The Journal of law, medicine & ethics: a journal of the American Society of Law, Medicine & Ethics, 43(1), 48-51.

Ventola, C. L. (2014). Mobile devices and apps for health care professionals: uses and benefits. P & T: a peer-reviewed journal for formulary management, 39(5), 356-64.

Wu, H., & LaRue, E. M. (2017). Linking the health data system in the U.S.: Challenges to the benefits. International Journal of Nursing Sciences, 4(4). 410-417.

Zeng, X. (2016). The Impacts of Electronic Health Record Implementation on the Health Care Workforce. North Carolina Medical Journal of Health Policy Analysis and Debate, 77(2). 112-114. Doi: 10.18043/ncm.77.2.112



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