Medical Records

Records Storage and Maintenance

Introduction  

Many hospitals and other health institutions are changing the way they keep the medical records. Though paper has been used for a long time, it is cumbersome and time wasting. Many health care providers are therefore using the computer to store the information. The process of transferring these records from the more traditional form to the computer is sensitive and one that should be treated with a lot of confidentiality. The government realizes that people are concerned about how their health information is used and it has come up with various measures to enhance security and limit access of this information. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 were formed to protect the privacy of a patient’s health information and they set the standard for security of electronic protected health information.

Health Insurance Portability and Accountability Act

The government has put in place stringent measures aimed at protecting all information. Title II of the HIPAA has five important rules to consider regarding health information. These rules include Privacy Rule, Security Rule, Transactions and Code Sets Rule, Enforcement Rule and Unique Identifiers Rule. Of all the rules, the Privacy and Security rules are the ones, which would affect the process of transferring information from paper to electronic format. All health information is protected by the Federal Law, under the Privacy Rule. This applies to all information, whether it is oral, written or in electronic format. The information stored in electronic form is also protected by the Security Rule (HHS 2010).

One of the safeguards under Security Rule is the physical safeguard. All those handling the data should be properly trained and they should know their responsibilities. There should be limited access to the hardware and software being used. This standard protects against inappropriate physical access to protected data. Technical safeguard is also very important. Covered entities should make sure that no private health information has been altered in any manner. Another rule to consider is the Enforcement Rule. This rule stipulates that whoever is found guilty of violating the HIPAA rules will pay a penalty (HIPAA 1996)

Electronic Medical Records (EMRs) are now in operation in the health care sector, but this is not to say that health care has completely abolished the use of paper. Though President Obama set aside $19 billion under the stimulus bill to enable health care givers transition to EMR, there are still reservations surrounding this move owing to a lack of guarantee that patient records will be maintained confidentially (Robins, 2010). In addition, there have been reported cases of people not privy to medical information gaining access to it despite the use of security codes such as passwords.

Most health care givers are concerned about protecting health information. In their view, it is easier to protect records that are on paper, contributing to the slow adoption of EMR. The Health Insurance Portability and Accountability Act (HIPPA) of 1996 requires medical institutions to keep patient records confidential, and imposes  penalties as high as $250,000 and 10 years imprisonment in breach of this law (Robins, 2010). The HIPPA is adhered to across the nation but different states have variations in regards to the right to medical information. In Nevada for instance, a patient is entitled see their medical record or get a copy of it, have information added to the medical record to make it more accurate, and file a complaint if the right to the information is violated.

Conclusion

Computer based medical records are an important factor to adopt in health facilities. From the discussion above, it is evident that both paper and computer systems have their pros and cons. It would be unfair to crucify one as useless or hail the other to be the most efficient. The important thing is to apply the method suitable in the different environments to reap maximum benefits from each.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References:

HHS. (2010). Health information privacy. U. S. Department of Health & Human Services. Retrieved 3 December 2010, from http://www.hhs.gov/ocr/privacy/

HIPAA. (1996). Health Insurance Portability and Accountability Act. Retrieved 3 December 2010, from http://aspe.hhs.gov/admnsimp/pl104191.htm

Mullins, R. (2009, September 17). What Are the Disadvantages of Electronic Medical Records? Retrieved from http://www.ehow.com/about_5187857_disadvantages-electronic-medical-records_.html

Robins, M. (2010). Electronic medical records: privacy risks and opportunities. Retrieved 3 December 2010, from http://www.huffingtonpost.com/marty-robins/electronic-medical-record_b_667990.html