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Journal articles on the topic 'Paper health records'
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Jayaseelan R. and Pichandy C. "Making the Paper-to-Digital Shift in India." International Journal of Information Communication Technologies and Human Development 12, no. 2 (April 2020): 15–28. http://dx.doi.org/10.4018/ijicthd.2020040102.
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This study explores the adoption of electronic health records system, an emerging technology, and its usage in the improvement of healthcare process in the Indian setting. Electronic health record (EHR) is a systematised digital version of a patient's complete medical history. It is a record containing all the aspects of patient care provided by physicians in a healthcare centre, maintained by the providers. Electronic health records system provides a means for improving healthcare standards, especially with regard to a developing nation. In the landscape of developing countries, like India, this technology evolution will bring major change by offering better healthcare services. The researchers through this study have called attention to examine the adoption of ICT, electronic health records system in particular, by medical doctors at their workspace applying TAM model.
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Tsai, J., and G. Bond. "A comparison of electronic records to paper records in mental health centers." International Journal for Quality in Health Care 20, no. 2 (December 11, 2007): 136–43. http://dx.doi.org/10.1093/intqhc/mzm064.
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Hawley, Glenda, Julie Hepworth, Claire Jackson, and Shelley A. Wilkinson. "Integrated care among healthcare providers in shared maternity care: what is the role of paper and electronic health records?" Australian Journal of Primary Health 23, no. 4 (2017): 397. http://dx.doi.org/10.1071/py16081.
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This study examines a paper hand-held record and a shared electronic health record in an Australian tertiary hospital healthcare maternity setting and the role that both types of records play in facilitating integrated care among healthcare providers. A qualitative research design was used where five focus groups were conducted in two phases with 69 hospital healthcare providers. In total, 32 interviews were also carried out with general practitioners. Transcripts were analysed using qualitative content analysis. Three key themes were identified: (1) selective use of records; (2) records as communication of care; and (3) negativity about the use of records. This study demonstrates that healthcare providers do not effectively share information using either a paper hand-held record or a shared electronic health record. Considering a national commitment to e-health innovation, a multi-professional input, organisational support and continuing education are identified as crucial to realising the potential of a maternity shared electronic health record to facilitate integrated care.
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Hawthorne, Kisha Hortman, and Lorraine Richards. "Personal health records: a new type of electronic medical record." Records Management Journal 27, no. 3 (November 20, 2017): 286–301. http://dx.doi.org/10.1108/rmj-08-2016-0020.
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Purpose This paper examines existing research on the topic of personal health records (PHRs). Areas covered include PHR/patient portal, recordkeeping, preservation planning, access and provider needs for future reuse of health information. Patient and physician PHR use and functionality, as well as adoption facilitators and barriers, are also reviewed. Design/methodology/approach The paper engages in a review of relevant literature from a variety of subject domains, including personal information management, medical informatics, medical literature and archives and records management literature. Findings The review finds that PHRs are extensions of electronic records. In addition, it finds a lack of literature within archives and records management that may lead to a less preservation-centric examination of the new PHR technologies that are desirable for controlling the lifecycle of these important new records-type. Originality/value Although the issues presented by PHRs are issues that can best be solved with the use of techniques from records management, there is no current literature related to PHRs in the records management literature, and that offered in the medical informatics literature treats the stewardship aspects of PHRs as insurmountable. This paper offers an introduction to the aspects of PHRs that could fruitfully be examined in archives and records management.
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Lambe, Gerard, Niall Linnane, Ian Callanan, and Marcus W. Butler. "Cleaning up the paper trail – our clinical notes in open view." International Journal of Health Care Quality Assurance 31, no. 3 (April 16, 2018): 228–36. http://dx.doi.org/10.1108/ijhcqa-09-2016-0126.
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Purpose Ireland’s physicians have a legal and an ethical duty to protect confidential patient information. Most healthcare records in Ireland remain paper based, so the purpose of this paper is to: assess the protection afforded to paper records; log highest risk records; note the variations that occurred during the working week; and observe the varying protection that occurred when staff, students and public members were present. Design/methodology/approach A customised audit tool was created using Sphinx software. Data were collected for three months. All wards included in the study were visited once during four discrete time periods across the working week. The medical records trolley’s location was noted and total unattended medical records, total unattended nursing records, total unattended patient lists and when nursing personnel, medical students, public and a ward secretary were visibly present were recorded. Findings During 84 occasions when the authors visited wards, unattended medical records were identified on 33 per cent of occasions, 49 per cent were found during weekend visiting hours and just 4 per cent were found during morning rounds. The unattended medical records belonged to patients admitted to a medical specialty in 73 per cent of cases and a surgical specialty in 27 per cent. Medical records were found unattended in the nurses’ station with much greater frequency when the ward secretary was off duty. Unattended nursing records were identified on 67 per cent of occasions the authors visited the ward and were most commonly found unattended in groups of six or more. Practical implications This study is a timely reminder that confidential patient information is at risk from inappropriate disclosure in the hospital. There are few context-specific standards for data protection to guide healthcare professionals, particularly paper records. Nursing records are left unattended with twice the frequency of medical records and are found unattended in greater numbers than medical records. Protection is strongest when ward secretaries are on duty. Over-reliance on vigilant ward secretaries could represent a threat to confidential patient information. Originality/value While other studies identified data protection as an issue, this study assesses how data security varies inside and outside conventional working hours. It provides a rationale and an impetus for specific changes across the whole working week. By identifying the on-duty ward secretary’s favourable effect on medical record security, it highlights the need for alternative arrangements when the ward secretary is off duty. Data were collected prospectively in real time, giving a more accurate healthcare record security snapshot in each data collection point.
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McDermott, Donna S., Jessica L. Kamerer, and Andrew T. Birk. "Electronic Health Records." International Journal of Cyber Research and Education 1, no. 2 (July 2019): 42–49. http://dx.doi.org/10.4018/ijcre.2019070104.
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Electronic health records (EHRs) pose unique concerns for administrators and information technology professionals with regard to cybersecurity. Due to the sensitive nature and increasing value of personal health information, cyber risks and information protection should be a high priority. A literature review was conducted to identify potential threat categories and best practices in protecting EHR information. Potential threats were identified and categorized into five areas; physical, portable devices, insider use, technical, and administrative. Government policies have created administrative, physical, and technical safeguards to keep EHR information safe. Despite these efforts, EHRs are being targeted by cyber-criminals due to flaws in personal and organizational management of protected healthcare information. This paper aims to educate, inform, and advocate for the proper handling of EHRs to alleviate the burden caused by compromised electronic documents.
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Simon, Melissa A., David S. Sanders, Sarah Read-Brown, and Michael F. Chiang. "Pediatric ophthalmology documentation using paper versus electronic health records." Journal of American Association for Pediatric Ophthalmology and Strabismus 18, no. 4 (August 2014): e37. http://dx.doi.org/10.1016/j.jaapos.2014.07.120.
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Lewis, Carol A. "Health Records in Developing Countries." Australian Medical Record Journal 18, no. 2 (June 1988): 47–50. http://dx.doi.org/10.1177/183335838801800204.
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Health record practitioners in developing countries lack contact with their peers in other countries. Consultants are a mechanism for transmitting information and new ideas from place to place. In this paper, the author describes a framework within which consultants may provide technical assistance in medical records. Discussion includes the dimensions of health record technical cooperation, the qualities expected of a consultant in developing countries, and the role of professional associations.
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Bourgeois, Stacy, and Ulku Yaylacicegi. "Electronic Health Records." International Journal of Healthcare Information Systems and Informatics 5, no. 3 (July 2010): 1–13. http://dx.doi.org/10.4018/jhisi.2010070101.
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Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. This study investigates how EHR use, as implemented and utilized, impacts patient safety and quality performance. Data in this paper include nonfederal acute care hospitals in the state of Texas, and the data sources include the American Hospital Association, the Dallas Fort Worth Hospital Council, and the American Hospital Directory. The authors use partial least squares modeling to assess the relationship between hospital EHR use, patient safety, and quality of care. Patient safety is measured using 11 indicators as identified by the Agency for Healthcare Research and Quality (AHRQ) and quality performance is measured by 11 mortality indicators as related to 2 constructs, that is, conditions and surgical procedures. Results identify positive significant relationships between EHR use, patient safety, and quality of care with respect to procedures. The authors conclude that there is sufficient evidence of the relationship between hospital EHR use and patient safety, and that sufficient evidence exists for the support of EHR use with hospital surgical procedures.
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Hawley, Glenda, Julie Hepworth, Shelley A. Wilkinson, and Claire Jackson. "From maternity paper hand-held records to electronic health records: what do women tell us about their use?" Australian Journal of Primary Health 22, no. 4 (2016): 339. http://dx.doi.org/10.1071/py14170.
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The paper hand-held record (PHR) has been used extensively in general practice (GP) shared care management of pregnant women, and recently, the first Mater Shared Electronic Health Record (MSEHR) was introduced. The aim of this qualitative study was to examine women’s experiences using the records and the contribution of the records to integrate care. At the 36-week antenatal visit in a maternity tertiary centre clinic, women were identified as a user of either the PHR or the MSEHR and organised into Phase 1 and Phase 2 studies respectively. Fifteen women were interviewed in Phase 1 and 12 women in Phase 2. Semi-structured interviews were used for data collection, and analysed using qualitative content analysis. Four main themes were identified: (1) purpose of the record, (2) perceptions of the record; (3) content of the record, and (4) sharing the record. Findings indicate that the PHR is a well-liked maternity tool. The findings also indicate there is under-usage of the MSEHR due to health-care providers failing to follow up and discuss the option of using the electronic health record option or if a woman has completed the log-in process. This paper adds to an already favourable body of knowledge about the use of the PHR. It is recommended that continued implementation of the MSEHR be undertaken to facilitate its use.
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Bailit, H. L. "Health Services Research." Advances in Dental Research 17, no. 1 (December 2003): 82–85. http://dx.doi.org/10.1177/154407370301700119.
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The major barriers to the collection of primary population-based dental services data are: (1) Dentists do not use standard record systems; (2) few dentists use electronic records; and (3) it is costly to abstract paper dental records. The value of secondary data from paid insurance claims is limited, because dentists code only services delivered and not diagnoses, and it is difficult to obtain and merge claims from multiple insurance carriers. In a national demonstration project on the impact of community-based dental education programs on the care provided to underserved populations, we have developed a simplified dental visit encounter system. Senior students and residents from 15 dental schools (approximately 200 to 300 community delivery sites) will use computers or scannable paper forms to collect basic patient demographic and service data on several hundred thousand patient visits. Within the next 10 years, more dentists will use electronic records. To be of value to researchers, these data need to be collected according to a standardized record format and to be available regionally from public or private insurers.
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Malhotra, Naveen, and Marlieta Lassiter. "The Coming Age Of Electronic Medical Records: From Paper To Electronic." International Journal of Management & Information Systems (IJMIS) 18, no. 2 (March 28, 2014): 117. http://dx.doi.org/10.19030/ijmis.v18i2.8493.
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Medical records, first developed in the fifth century, have remained virtually unchanged until the explosion of new technology in the mid-1960s. The National Space and Aeronautics Administrations development of computerized patient record (CPR) brought life to the electronic medical record (EMR) industry. Preventable deaths due to medical errors drew the attention of public and health care professionals to the need for increased patient safety and improved quality measures in medicine. With health care costs compromising 16-17% of the U.S. Gross Domestic Product, Congress passed legislation to financially support providers to adopt electronic medical record (EMR). As a result, future efforts will focus on the sharing of information among all health care stakeholders. Across the world, governments, technology companies, and care providers are collaborating efforts to make the EMR a reality.
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Koh, Justin, and Mansoor Ahmed. "Improving clinical documentation: introduction of electronic health records in paediatrics." BMJ Open Quality 10, no. 1 (February 2021): e000918. http://dx.doi.org/10.1136/bmjoq-2020-000918.
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Medical records are crucial facet of a patient’s journey. These provide the clinician with a permanent record of the patient’s illness and ongoing medical care, thus enabling informed clinical decisions. In many hospitals, patient medical records are written on paper. However, written notes are liable to misinterpretation due to illegibility and misplacement. This can affect the patient’s medical care and has medico-legal implications. Electronic patient records (EPR) have been gradually introduced to replace patient’s paper notes with the aim of providing a more reliable record-keeping system. It is perceived that EPR improve the quality and efficiency of patient care. The paediatric department at Queen’s Hospital Burton uses a mix of paper notes and computerised medical records. Clinicians primarily use paper notes for admission clerking, ward rounds, ward reviews and outpatient clinic consultations. Laboratory tests, imaging results and prescription requests are executed via the EPR system. Documentation by nurses is also carried out electronically. We aimed to improve and standardise clinical documentation of paediatric admissions and ward round notes by developing electronic proforma for initial paediatric clerking, ward rounds and patient reviews. This quality improvement project improved clinical documentation on the paediatric wards and enhanced patient record-keeping, boosted clinical information-sharing and streamlined patient journey. It fulfilled various generic multidisciplinary record keeping audit tool standards endorsed by the Royal College of Physicians by 100%. We undertook a staff survey to investigate the opinion before and after implementing the electronic health record. Doctors, nurses and healthcare support workers overwhelmingly supported the quality, usefulness, completeness of specified fields and practicality of the electronic records.
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Gans, D., J. White, R. Nath, J. Pohl, and C. Tanner. "Electronic Health Records and Patient Safety." Applied Clinical Informatics 06, no. 01 (2015): 136–47. http://dx.doi.org/10.4338/aci-2014-11-ra-0099.
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Summary Background: The role of electronic health records (EHR) in enhancing patient safety, while substantiated in many studies, is still debated. Objective: This paper examines early EHR adopters in primary care to understand the extent to which EHR implementation is associated with the workflows, policies and practices that promote patient safety, as compared to practices with paper records. Early adoption is defined as those who were using EHR prior to implementation of the Meaningful Use program. Methods: We utilized the Physician Practice Patient Safety Assessment (PPPSA) to compare primary care practices with fully implemented EHR to those utilizing paper records. The PPPSA measures the extent of adoption of patient safety practices in the domains: medication management, handoffs and transition, personnel qualifications and competencies, practice management and culture, and patient communication. Results: Data from 209 primary care practices responding between 2006–2010 were included in the analysis: 117 practices used paper medical records and 92 used an EHR. Results showed that, within all domains, EHR settings showed significantly higher rates of having workflows, policies and practices that promote patient safety than paper record settings. While these results were expected in the area of medication management, EHR use was also associated with adoption of patient safety practices in areas in which the researchers had no a priori expectations of association. Conclusions: Sociotechnical models of EHR use point to complex interactions between technology and other aspects of the environment related to human resources, workflow, policy, culture, among others. This study identifies that among primary care practices in the national PPPSA database, having an EHR was strongly empirically associated with the workflow, policy, communication and cultural practices recommended for safe patient care in ambulatory settings. Citation: Tanner C, Gans D, White J, Nath R, Pohl J. Electronic health records and patient safety – co-occurrence of early EHR implementation with patient safety practices in primary care settings. Appl Clin Inf 2015; 6: 136–147http://dx.doi.org/10.4338/ACI-2014-11-RA-0099
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Cahyaharnita, Rezky Ami. "Synchronization of Electronic Medical Record Implementation Guidelines in National E-Health Strategies." SOEPRA 5, no. 2 (April 2, 2020): 209. http://dx.doi.org/10.24167/shk.v5i2.2430.
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Medical records are made in writing, complete and clear or electronically. Medical records are the basis of medical services to patients. Paper medical records increase the amount of paper waste in Indonesia. A national e-health strategy is a comprehensive approach to efforts in the national health sector. Electronic medical records are more effective because of better time management. The formulation of the problem in this article covers the reasons, criteria, and implementation of electronic medical records. The research method used is descriptive qualitative research with a statute approach. The criteria for a good electronic medical record are integrated data from various sources, data collected at the service point, and supporting service providers in decision making. The expected electronic medical record is to be integrated with the health service facility information system program without neglecting the confidentiality aspect. Therefore, the government needs to make regulations on the technical implementation of electronic medical records.
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Dewri, Rinku, Toan Ong, and Ramakrishna Thurimella. "Linking Health Records for Federated Query Processing." Proceedings on Privacy Enhancing Technologies 2016, no. 3 (July 1, 2016): 4–23. http://dx.doi.org/10.1515/popets-2016-0013.
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Abstract A federated query portal in an electronic health record infrastructure enables large epidemiology studies by combining data from geographically dispersed medical institutions. However, an individual’s health record has been found to be distributed across multiple carrier databases in local settings. Privacy regulations may prohibit a data source from revealing clear text identifiers, thereby making it non-trivial for a query aggregator to determine which records correspond to the same underlying individual. In this paper, we explore this problem of privately detecting and tracking the health records of an individual in a distributed infrastructure. We begin with a secure set intersection protocol based on commutative encryption, and show how to make it practical on comparison spaces as large as 1010 pairs. Using bigram matching, precomputed tables, and data parallelism, we successfully reduced the execution time to a matter of minutes, while retaining a high degree of accuracy even in records with data entry errors. We also propose techniques to prevent the inference of identifier information when knowledge of underlying data distributions is known to an adversary. Finally, we discuss how records can be tracked utilizing the detection results during query processing.
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Allen-Graham, Judith, Lauren Mitchell, Natalie Heriot, Roksana Armani, David Langton, Michele Levinson, Alan Young, Julian A. Smith, Tom Kotsimbos, and John W. Wilson. "Electronic health records and online medical records: an asset or a liability under current conditions?" Australian Health Review 42, no. 1 (2018): 59. http://dx.doi.org/10.1071/ah16095.
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Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information. Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital’s current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary. Results Of all medical records audited, 82% contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49% of records audited showed evidence the discharge summary was sent outside the institution. Conclusions The quality of medical data captured and information management is variable across hospitals. It is recommended that medical history documentation guidelines and standardised discharge summaries be implemented in Australian healthcare services. What is known about this topic? Australia has a complex health system, the government has approved funding to develop a universal online electronic medical record system and is currently trialling this in an opt-out style in the Napean Blue Mountains (NSW) and in Northern Queensland. The system was originally named the personally controlled electronic health record but has since been changed to MyHealth Record (2016). In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This causes inefficiencies in the recall of patient information and can potentially lead to incidences of adverse drug events. What does this paper add? This paper supports the concept of a shared medical record system using 200 audited patient records across five Victorian metropolitan hospitals, comparing the current information systems in place for healthcare practitioners to retrieve data. This research identifies the degree of concordance between these sources of information and in doing so, areas for improvement. What are the implications for practitioners? Implications of this research are the improvements in the quality, storage and accessibility of medical data in Australian healthcare systems. This is a relevant issue in the current Australian environment where no guidelines exist across the board in medical history documentation or in the distribution of discharge summaries to other healthcare providers (general practitioners, etc).
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Marcu, Gabriela, Anind K. Dey, and Sara Kiesler. "Tensions in Representing Behavioral Data in an Electronic Health Record." Computer Supported Cooperative Work (CSCW) 30, no. 3 (June 2021): 393–424. http://dx.doi.org/10.1007/s10606-021-09402-7.
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AbstractTaking an action research approach, we engaged in fieldwork with school-based behavioral health care teams to: observe record keeping practices, design and deploy a prototype system addressing key challenges, and reflect on its use. We describe the challenges of capturing behavioral data using both paper and electronic records. Creating records of behaviors requires direct observation, and as a result the record keeping responsibility is challenging to distribute across a care team. Behavioral data on paper must be transferred and prepared for reporting, both inside the organization and to stakeholders outside of the organization. In prototyping a computerized working record, we targeted user needs for capturing details of a behavioral incident in the moment. Challenges persisted through the transition from paper to our prototype, and based on these empirical findings over two years of fieldwork, we present five tensions in representing behavioral data in an electronic health record. These tensions reflect the differences between entering behavioral data into the record for intraorganizational use versus interorganizational use.
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Ali, Syed, Farah Naureen, Arif Noor, Maged Kamel Boulos, Javariya Aamir, Muhammad Ishaq, Naveed Anjum, et al. "Data Quality: A Negotiator between Paper-Based and Digital Records in Pakistan’s TB Control Program." Data 3, no. 3 (July 19, 2018): 27. http://dx.doi.org/10.3390/data3030027.
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Background: The cornerstone of the public health function is to identify healthcare needs, to influence policy development, and to inform change in practice. Current data management practices with paper-based recording systems are prone to data quality defects. Increasingly, healthcare organizations are using technology for the efficient management of data. The aim of this study was to compare the data quality of digital records with the quality of the corresponding paper-based records using a data quality assessment framework. Methodology: We conducted a desk review of paper-based and digital records over the study duration from April 2016 to July 2016 at six enrolled tuberculosis (TB) clinics. We input all data fields of the patient treatment (TB01) card into a spreadsheet-based template to undertake a field-to-field comparison of the shared fields between TB01 and digital data. Findings: A total of 117 TB01 cards were prepared at six enrolled sites, whereas just 50% of the records (n = 59; 59 out of 117 TB01 cards) were digitized. There were 1239 comparable data fields, out of which 65% (n = 803) were correctly matched between paper based and digital records. However, 35% of the data fields (n = 436) had anomalies, either in paper-based records or in digital records. The calculated number of data quality issues per digital patient record was 1.9, whereas it was 2.1 issues per record for paper-based records. Based on the analysis of valid data quality issues, it was found that there were more data quality issues in paper-based records (n = 123) than in digital records (n = 110). Conclusion: There were fewer data quality issues in digital records as compared with the corresponding paper-based records of tuberculosis patients. Greater use of mobile data capture and continued data quality assessment can deliver more meaningful information for decision making.
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Svensson Sehic, Anna, Mikaela Persson, Eva K. Clausson, and Eva-Lena Einberg. "Nurse Documentation of Child Weight-Related Health Promotion at Age Four in Sweden." Nursing Reports 11, no. 1 (February 2, 2021): 75–83. http://dx.doi.org/10.3390/nursrep11010008.
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(1) Background: Overweight and obesity in children have increased worldwide and tend to persist into adolescence and adulthood. The Child Health Service (CHS) has an important role in providing health-promotive interventions, and such interventions are required to be documented in a child’s health record. The aim of the study was to investigate Child Health Care (CHC) nurses’ documentation of weight-related, health-promotive interventions in the Child Health Care Record (CHCR) regarding lifestyle habits in connection to the four-year visit. (2) Methods: A record review of 485 CHCRs using a review template was accomplished. Of the included CHS units, four used electronic records and two used paper records. Chi-square tests and Spearman’s rank-order correlations were used to analyse data. (3) Results: The results showed that CHC nurses document interventions regarding lifestyle habits to a low extent, although children with overweight/obesity seemed to undergo more interventions. There was also a difference between electronic and paper records. (4) Conclusions: The consequences of not documenting the interventions in the CHCR make it difficult to follow up and demonstrate the quality of the CHC nurse’s work. There is a need for more research to gain a deeper understanding of the reasons that the work of CHC nurses is not visible in children’s health records.
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Cahyani, Prilian, and Astutik Astutik. "Criminal Liability for Misuse of Electronic Medical Records in Health Services." SOEPRA 5, no. 2 (April 2, 2020): 215. http://dx.doi.org/10.24167/shk.v5i2.2431.
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Electronic medical records (RME) have been used in hospitals as a substitute for or complementary to medical records in the form of paper. The obligation to make medical records is the responsibility of every doctor or dentist in carrying out the medical practice. However, the use of electronic-based medical records does not rule out the possibility of raising problems in the field of law, if some abuse it. This will raise the issue of who has the obligation to take responsibility. The problem is the background of the author to write in an article with the title "Accountability for the Misuse of Electronic Medical Record Abuse in Health Services". The formulation of the problem in this article is: 1) Setting an electronic medical record; 2) Criminal liability for the misuse of electronic medical records. The research method used is normative legal research with a statutory approach and a conceptual approach. From the discussion, it can be seen that in Indonesia the obligation to make medical records is specifically regulated in the Medical Practice Law. Furthermore, in the Ministry of Health No. 269 / MENKES / PER / III / 2008 especially Article 2 paragraph 2 states that medical records can be made electronically. However, to date, no specific regulations are governing electronic medical records. The use of electronic systems in medical records makes it necessary to heed the provisions of Law No. 11 of 2008 concerning Electronic Information and Transactions. The party who has the responsibility for the misuse of the Electronic Medical Record covers people who in this case are medical personnel or certain health workers. Hospitals can also be held responsible for the misuse of electronic medical records.
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SHENOY, AKHIL, and JACOB M. APPEL. "Safeguarding Confidentiality in Electronic Health Records." Cambridge Quarterly of Healthcare Ethics 26, no. 2 (March 31, 2017): 337–41. http://dx.doi.org/10.1017/s0963180116000931.
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Abstract:Electronic health records (EHRs) offer significant advantages over paper charts, such as ease of portability, facilitated communication, and a decreased risk of medical errors; however, important ethical concerns related to patient confidentiality remain. Although legal protections have been implemented, in practice, EHRs may be still prone to breaches that threaten patient privacy. Potential safeguards are essential, and have been implemented especially in sensitive areas such as mental illness, substance abuse, and sexual health. Features of one institutional model are described that may illustrate the efforts to both ensure adequate transparency and ensure patient confidentiality. Trust and the therapeutic alliance are critical to the provider–patient relationship and quality healthcare services. All of the benefits of an EHR are only possible if patients retain confidence in the security and accuracy of their medical records.
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Thu, Sai Wai Yan Myint, Boonchai Kijsanayotin, Jaranit Kaewkungwal, Ngamphol Soonthornworasiri, and Wirichada Pan-ngum. "Satisfaction with Paper-Based Dental Records and Perception of Electronic Dental Records among Dental Professionals in Myanmar." Healthcare Informatics Research 23, no. 4 (2017): 304. http://dx.doi.org/10.4258/hir.2017.23.4.304.
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Intan Idayu Binti Shahrul Asari, Seri, Nurussobah Binti Hussin, Ahmad Zam Hariro Bin Samsudin, and Mohd Nizam Bin Yunus. "Recordkeeping Metadata Standardization for Electronic Health Records System Integration: a Preliminary Study." International Journal of Engineering & Technology 7, no. 3.7 (July 4, 2018): 266. http://dx.doi.org/10.14419/ijet.v7i3.7.16388.
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Electronic Health Records (EHRs) are beneficial in improving patient care, promoting safe practice, as well as enhancing patients and multiple providers’ communication and risk error reduction. However, it seems that the adoption of EHR system is happening very slowly to become fully integrated in both primary care and within hospital settings. In Malaysia, the implemented system still has limited integration and interoperability for supporting clinical operations among other Ministry of Health Malaysia (MOHM) hospitals, health centres, and clinics. Therefore, the objective of this paper is to discuss about this scenario and strain the need for solution through the consideration towards metadata standard establishment in health records system integration. Method used in this study is literature review analysis and face-to-face interview. The paper begins with discussions from various literatures highlighting the need of metadata standard for recordkeeping system integration. Subsequently, the face-to-face interview is done to explore the real situation in Malaysia to encounter the scenario discuss in the literatures. The finding of this study reveals that there is significant need for further research on record keeping metadata standard development for realization of electronic health records system integration. This study is significant for records managers, information technology managers, system developers and record keeping audit.
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vonKoss Krowchuk, Heidi, Mary L. Moore, and Lenora Richardson. "Using Health Care Records as Sources of Data for Research." Journal of Nursing Measurement 3, no. 1 (January 1995): 3–12. http://dx.doi.org/10.1891/1061-3749.3.1.3.
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Health care records are comprehensive in nature, and provide continuity of health care; therefore, they are vital components in the delivery of services. Health care records also are extremely important for researchers, since they are a rich source of critical information, and the documentation in them is considered to be legally and medically accurate and reliable. This paper examines the advantages and disadvantages of using health care records as data sources for research and discusses the research method issues related to these data sources. The issues addressed are illustrated with examples from three large studies in which health care record reviews represented the only source of data or were a primary information source.
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Calero, Coral, José Luis Fernández-Alemán, Javier Mancebo, José A. García-Berná, Félix García, and Ambrosio Toval. "Energy Efficiency of Personal Health Records." Proceedings 2, no. 19 (October 16, 2018): 510. http://dx.doi.org/10.3390/proceedings2190510.
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Personal Health Records (PHR) are electronic tools managed by the patients themselves, allowing them to store and consult health data anywhere and at any time using an electronic device. Precisely because of the type of users they are aimed at, it is essential to guarantee that PHR are easy to use. However, having a PHR that is usable does not mean that it is the best in terms of energy efficiency. Taking into account the large number of users that this type of portal is aimed at, achieving savings in energy consumption when running the portal’s tasks can have a considerable impact. In this paper we present an initial approach that studies the interaction between usability and energy efficiency of PHRs, attempting to determine if a given PHR makes efficient use of the resources it needs for the execution of its tasks. To do this, we have used the EET device, which allows us to collect the consumption of different hardware components when running software (in our case the PHR), and the usability criteria defined by Dix.
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Astrid, M. "The Structure of Data in Medical Records." Yearbook of Medical Informatics 04, no. 01 (August 1995): 61–70. http://dx.doi.org/10.1055/s-0038-1638021.
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Abstract:With the growing complexity of health care, patient data are more and more in demand for purposes such as research, education, postmarketing surveillance, quality assessment, and outcome analysis. Many of these purposes require patient data to be available in a structured, electronic format. Despite the rapid advances in computer technology, which allow patient data to be organized, analyzed, and shared, the majority of physicians still use paper medical records. Apparently, most physicians still perceive the paper record as being more suitable for their task than present day computerized versions. Both the shortcomings and the strengths of paper medical records have been identified and it proves difficult to design a computerized medical record that exploits the strengths of computers without loosing the advantages of the paper chart. The structure of patient data is an area of high interest, since structure determines how physicians, other health care workers, and patients may benefit from these data. An overview of research efforts in structuring patient data will offer insight in the problems that still impede a widespread use of the computerized patient record in clinical practice.
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Bhardwaj, Aashish, and Vikas Kumar. "Electronic Healthcare Records." International Journal of Service Science, Management, Engineering, and Technology 12, no. 2 (March 2021): 44–58. http://dx.doi.org/10.4018/ijssmet.2021030103.
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Patient data is very valuable and must be protected from misuse by the third parties. Also, the rights of patient like privacy, confidentiality of medical information, information about possible risks of medical treatment, to consent or refuse a treatment are very much important. Individuals should have the right to access their health records and get these deleted from hospital records after completing the treatment. Traditional ways of keeping paper-based health records are being replaced by electronic health records as they increase portability and accessibility to medical records. Governments and hospitals across the world and putting huge efforts to implement the electronic health records. The present work explores the different aspects of health privacy and health records. Most important stakeholders, technological and legal aspects have been presented from both the Indian and international perspectives. A comparative analysis has been presented for the available EHR standards with a focus on their roles and implementation challenges.
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Pourasghar, Faramarz, Hossein Malekafzali, Sabine Koch, and Uno Fors. "Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: An Iranian case study." International Journal of Technology Assessment in Health Care 24, no. 04 (October 2008): 445–51. http://dx.doi.org/10.1017/s0266462308080586.
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Objectives:Information technology is a rapidly expanding branch of science which has affected other sciences. One example of using information technology in medicine is the Electronic Medical Records system. One medical university in Iran decided to introduce such system in its hospital. This study was designed to identify the factors which influence the quality of medical documentation when paper-based records are replaced with electronic records.Methods:A set of 300 electronic medical records was randomly selected and evaluated against eleven checklists in terms of documentation of medical information, availability, accuracy and ease of use. To get the opinion of the care-providers on the electronic medical records system, ten physicians and ten nurses were interviewed by using of semi-structured guidelines. The results were also compared with a prior study with 300 paper-based medical records.Results:The quality of documentation of the medical records was improved in areas where nurses were involved, but those parts which needed physicians' involvement were actually worse. High workloads, shortage of bedside hardware and lack of software features were prominent influential factors in the quality of documentation. The results also indicate that the retrieval of information from the electronic medical records is easier and faster, especially in emergency situations.Conclusions:The electronic medical records system can be a good substitute for the paper-based medical records system. However, according to this study, some factors such as low physician acceptance of the electronic medical record system, lack of administrative mechanisms (for instance supervision, neglecting physicians and/or nurses in the development and implementation phases and also continuous training), availability of hardware as well as lack of specific software features can negatively affect transition from a paper-based system to an electronic system.
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Shull, Jessica Germaine. "Digital Health and the State of Interoperable Electronic Health Records." JMIR Medical Informatics 7, no. 4 (November 1, 2019): e12712. http://dx.doi.org/10.2196/12712.
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Digital health systems and innovative care delivery within these systems have great potential to improve national health care and positively impact the health outcomes of patients. However, currently, very few countries have systems that can implement digital interventions at scale. This is partly because of the lack of interoperable electronic health records (EHRs). It is difficult to make decisions for an individual or population when the data on that person or population are dispersed over multiple incompatible systems. This viewpoint paper has highlighted some key obstacles of current EHRs and some promising successes, with the goal of promoting EHR evolution and advocating for frameworks that develop digital health systems that serve populations—a critical goal as we move further into this data-rich century with an ever-increasing number of patients who live longer and depend on health care services where resources may already be strained. This paper aimed to analyze the evolution, obstacles, and current landscape of EHRs and identify fundamental areas of hindrance for interoperability. It also aimed to highlight countries where advances have been made and extract best practices from these examples. The obstacles to EHR interoperability are not easily solved, but improving the current situation in countries where a national policy is not in place will require a focused inquiry into solutions from various sources in the public and private sector. Effort must be made on a national scale to seek solutions for optimally interoperable EHRs beyond status quo solutions. A list of considerations for best practices is suggested.
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Ravi, Reshma, and emya R. "Review Paper on Graph Based Approach for Mining Health Examination Records Using Views." International Journal of Computer Sciences and Engineering 5, no. 11 (November 30, 2017): 64–67. http://dx.doi.org/10.26438/ijcse/v5i11.6467.
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Fenz, Stefan, Johannes Heurix, Thomas Neubauer, and Antonio Rella. "De-identification of unstructured paper-based health records for privacy-preserving secondary use." Journal of Medical Engineering & Technology 38, no. 5 (May 19, 2014): 260–68. http://dx.doi.org/10.3109/03091902.2014.913080.
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Liebman, Daniel L., Michael F. Chiang, and James Chodosh. "Realizing the Promise of Electronic Health Records: Moving Beyond “Paper on a Screen”." Ophthalmology 126, no. 3 (March 2019): 331–34. http://dx.doi.org/10.1016/j.ophtha.2018.09.023.
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Foster, Lauren M., Monica M. Cuddy, David B. Swanson, Kathleen Z. Holtzman, Maya M. Hammoud, and Paul M. Wallach. "Medical Student Use of Electronic and Paper Health Records During Inpatient Clinical Clerkships." Academic Medicine 93, no. 11S (November 2018): S14—S20. http://dx.doi.org/10.1097/acm.0000000000002376.
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Yuliartanto, Purnaresa, Adian Fatchur Rochim, and Ike Pertiwi Windasari. "Pengembangan Sistem Informasi Rekam Medis untuk Dinas Kabupaten Grobogan." Jurnal Teknologi dan Sistem Komputer 2, no. 3 (August 31, 2014): 203–8. http://dx.doi.org/10.14710/jtsiskom.2.3.2014.203-208.
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Abstract - Health services include the recording of the patient's medical record . Medical records were used to aid the treatment process. The number of medical records continues to grow proportional to the number of patients. Tens of thousands of sheets of paper used to record medical record requires effort , time and place great . The amount of effort will continue to grow each day. Search one sheet of medical records among a set of storage shelves requires considerable time and risk data is not found. The risk of error in the search and storing will increase every day. The development of technology allows the implementation of technology in the process of record-keeping. Changes in the form of digital medical records will reduce the need of a previous process. Labor, time and place required by the help of information systems will be reduced significantly . Storage process data stored in the cloud will provide more value for the system as a patient's medical records from a health center can be accessed from other health centers. The development of this system will reduce the risk of inappropriate storage and retrieval of medical records. Grobogan Health Department that oversees health center in Grobogan are office that are ready to migrate business processes into the digital age. Development of medical record information system for the health center expected to improve the quality of service of health centers , especially in health care.
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Marutha, Ngoako Solomon. "Landscaping health-care system using functional records management activities." Collection and Curation 40, no. 1 (May 14, 2020): 9–14. http://dx.doi.org/10.1108/cc-03-2020-0006.
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Purpose The paper sought to investigate the landscaping of electronic system through the use of the functional patient’s records management activities. The rationale is to share views and guide organisations that are struggling with providing specification for a functional records management system. Design/methodology/approach The study used qualitative approach to apply the literature in supporting the views about landscaping electronic system using functional patient’s records management activities. Findings The study revealed that without consideration of records management activities the likelihood is that the system may be not properly functional. The best way to landscape electronic system for records management is using records management activities. This will assist in avoiding critical omission for inclusion of all records management system operational activities. Originality/value The paper is proposing a new way of landscaping the electronic system by using the records management functional activities. It also provides a framework to guide the implementers or electronic system developers. The paper was partially extracted from the author’s Ph.D. thesis completed in 2016, to develop a framework for landscaping the electronic system by using the records management functional activities.
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Li, Yao, Qixun Qu, Meng Wang, Liheng Yu, Jun Wang, Linghao Shen, and Kunlun He. "Deep learning for digitizing highly noisy paper-based ECG records." Computers in Biology and Medicine 127 (December 2020): 104077. http://dx.doi.org/10.1016/j.compbiomed.2020.104077.
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Carine, Fiona, and Anita Walker. "Establishing Electronic Patient Record Standards Using Paper-Based Record Functions and Standards." Health Information Management 27, no. 2 (June 1997): 78–82. http://dx.doi.org/10.1177/183335839702700207.
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The South Australian Health Commission has embarked on a long term project to establish an Electronic Patient Record (EPR) for South Australia. The process requires extensive evaluation at the conclusion of each phase of development using a range of existing and purpose-developed evaluation tools. This paper describes a purpose-developed evaluation tool that uses the functional aspects of, and existing standards for, paper-based medical records in hospitals as its basis. The resulting EPR Standards are a tool which can be used to establish a benchmark against which to evaluate the efficiency and effectiveness of an electronic patient record.
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Rostamzadeh, Neda, Sheikh S. Abdullah, and Kamran Sedig. "Visual Analytics for Electronic Health Records: A Review." Informatics 8, no. 1 (February 23, 2021): 12. http://dx.doi.org/10.3390/informatics8010012.
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The increasing use of electronic health record (EHR)-based systems has led to the generation of clinical data at an unprecedented rate, which produces an untapped resource for healthcare experts to improve the quality of care. Despite the growing demand for adopting EHRs, the large amount of clinical data has made some analytical and cognitive processes more challenging. The emergence of a type of computational system called visual analytics has the potential to handle information overload challenges in EHRs by integrating analytics techniques with interactive visualizations. In recent years, several EHR-based visual analytics systems have been developed to fulfill healthcare experts’ computational and cognitive demands. In this paper, we conduct a systematic literature review to present the research papers that describe the design of EHR-based visual analytics systems and provide a brief overview of 22 systems that met the selection criteria. We identify and explain the key dimensions of the EHR-based visual analytics design space, including visual analytics tasks, analytics, visualizations, and interactions. We evaluate the systems using the selected dimensions and identify the gaps and areas with little prior work.
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Khedr, Dr Ayman E., and Fahad Kamal Alsheref. "A Proposed Electronic Health Record Content Structure Based on Clinical Organizations Survey." INTERNATIONAL JOURNAL OF COMPUTERS & TECHNOLOGY 15, no. 13 (October 22, 2014): 5233–46. http://dx.doi.org/10.24297/ijct.v15i13.5283.
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Computer systems and communication technologies made a strong and influential presence in the different fields of medicine. The cornerstone of a functional medical information system is the Electronic Health Records (EHR) management system. Several electronic health records systems were implemented in different states with different clinical data structures that prevent data exchange between systems even in the same state. This leads to the important barrier in implementing EHR system which is the lack of standards of EHR clinical data structure. In this paper we made a survey on several in international and Egyptian medical organization for implementing electronic health record systems for finding the best electronic health record clinical data structure that contains all patient’s medical data. We proposed an electronic health record system with a standard clinical data structure based on the international and Egyptian medical organization survey and with avoiding the limitations in the other electronic health record that exists in the survey.
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Edwards, A., L. M. Kern, and R. Kaushal. "Association between Electronic Health Records and Health Care Utilization." Applied Clinical Informatics 06, no. 01 (2015): 42–55. http://dx.doi.org/10.4338/aci-2014-10-ra-0089.
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SummaryBackground: The federal government is investing approximately $20 billion in electronic health records (EHRs), in part to address escalating health care costs. However, empirical evidence that provider use of EHRs decreases health care costs is limited.Objective: To determine any association between EHRs and health care utilization.Methods: We conducted a cohort study (2008–2009) in the Hudson Valley, a multi-payer, multi-provider community in New York State. We included 328 primary care physicians in predominantly small practices (median practice size four primary care physicians), who were caring for 223,772 patients. Data from an independent practice association was used to determine adoption of EHRs. Claims data aggregated across five commercial health plans was used to characterize seven types of health care utilization: primary care visits, specialist visits, radiology tests, laboratory tests, emergency department visits, hospital admissions, and readmissions. We used negative binomial regression to determine associations between EHR adoption and each utilization outcome, adjusting for ten physician characteristics.Results: Approximately half (48%) of the physicians were using paper records and half (52%) were using EHRs. For every 100 patients seen by physicians using EHRs, there were 14 fewer specialist visits (adjusted p < 0.01) and 9 fewer radiology tests (adjusted p = 0.01). There were no significant differences in rates of primary care visits, laboratory tests, emergency department visits, hospitalizations or readmissions.Conclusions: Patients of primary care providers who used EHRs were less likely to have specialist visits and radiology tests than patients of primary care providers who did not use EHRs.Citation: Kaushal R, Edwards A, Kern LM, with the HITEC Investigators. Association between electronic health records and health care utilization. Appl Clin Inf 2015; 6: 42–55http://dx.doi.org/10.4338/ACI-2014-10-RA-0089
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Knaup, P. "Section 2: Patient Records: Electronic Patient Records and their Benefit for Patient Care." Yearbook of Medical Informatics 15, no. 01 (August 2006): 40–42. http://dx.doi.org/10.1055/s-0038-1638475.
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SummaryTo summarize current excellent research in the field of patient records.Synopsis of the articles selected for the IMIA Yearbook 2006.Current research in the field of patient records analyses users’ needs and attitudes as well as the potential and limitations of electronic patient record systems. Particular topics are the questions physicians have when assessing patients during ward rounds, the timeliness of results when ordered electronically, the quality of documenting haemophilia home therapy, attitudes towards patient access to health records and adequate strategies for record linkage in dependence on the intended purpose.The best paper selection of articles on patient records shows examples of excellent research on methods used for the management of patient records and for processing their content as well as assessing the potential, limitations of and user attitudes towards electronic patient record systems. Computerized patient records are mature, so that they can contribute to high quality patient care and efficient patient management.
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Chishima, Kayako, Yoshiki Toyokuni, Kondo Hisayoshi, Yuichi Koido, and Tatsuhiko Kubo. "Current Status of the Japanese Disaster Medical Record." Prehospital and Disaster Medicine 34, s1 (May 2019): s114. http://dx.doi.org/10.1017/s1049023x19002425.
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Introduction:There was no common medical record used in disasters in Japan. At the 2011 Great East Japan Earthquake, medical teams used their own medical records instead of a unified format and operational rules. As a result, confusion occurred at the clinical practice site. The Joint Committee on Medical Records proposed a standard format of disaster medical records in February 2015. The Ministry of Health, Labor, and Welfare has issued the notification of states’ use of a standardized medical record for disaster in 2017. It was confirmed that standardized disaster medical records were used by each organization in the 2018 Western Japan torrential rain disaster and the Hokkaido Iburi Eastern Earthquake, but the actual condition of those records was not clarified.Methods:We sent a questionnaire to the local governments where the medical team worked in 2018 Western Japan torrential rain disaster and the Hokkaido Iburi Eastern Earthquake. In the questionnaire, we asked about the operation and management of standardized disaster medical records at the time of the disaster and also questioned future management methods.Results:There was no use of other medical records. Standardized medical records were used in all records. All records were managed and operated by the disaster medical headquarters responsible for health care and welfare. Standardized disaster medical records were recorded on paper. Evacuees included patients who moved from shelter to shelter or to temporary housing to get better living conditions. That created difficulties transferring records since it was recorded on paper and stored in medical headquarters. Some returning patients were checked by several medical teams, resulting in the creation of several medical records of the same patient’s condition. Future improvements and management of the recording process and record-keeping are required.
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Knaup, P., E. J. S. Hovenga, S. Heard, and S. Garde. "Towards Semantic Interoperability for Electronic Health Records." Methods of Information in Medicine 46, no. 03 (2007): 332–43. http://dx.doi.org/10.1160/me5001.
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Summary Objectives: In the field of open electronic health records (EHRs), openEHR as an archetype-based approach is being increasingly recognised. It is the objective of this paper to shortly describe this approach, and to analyse how openEHR archetypes impact on health professionals and semantic interoperability. Methods: Analysis of current approaches to EHR systems, terminology and standards developments. In addition to literature reviews, we organised face-to-face and additional telephone interviews and tele-conferences with members of relevant organisations and committees. Results: The openEHR archetypes approach enables syntactic interoperability and semantic interpretability – both important prerequisites for semantic interoperability. Archetypes enable the formal definition of clinical content by clinicians. To enable comprehensive semantic interoperability, the development and maintenance of archetypes needs to be coordinated internationally and across health professions. Domain knowledge governance comprises a set of processes that enable the creation, development, organisation, sharing, dissemination, use and continuous maintenance of archetypes. It needs to be supported by information technology. Conclusions: To enable EHRs, semantic interoperability is essential. The openEHR archetypes approach enables syntactic interoperability and semantic interpretability. However, without coordinated archetype development and maintenance, ‘rank growth’ of archetypes would jeopardize semantic interoperability. We therefore believe that openEHR archetypes and domain knowledge governance together create the knowledge environment required to adopt EHRs.
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Green, Tyler, Terry Smith, Richard Hodges, and W. Mark Fry. "A simple and inexpensive way to document simple husbandry in animal care facilities using QR code scanning." Laboratory Animals 51, no. 6 (July 3, 2017): 656–59. http://dx.doi.org/10.1177/0023677217718004.
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Record keeping within research animal care facilities is a key part of the guidelines set forth by national regulatory bodies and mandated by federal laws. Research facilities must maintain records of animal health issues, procedures and usage. Facilities are also required to maintain records regarding regular husbandry such as general animal checks, feeding and watering. The level of record keeping has the potential to generate excessive amounts of paper which must be retained in a fashion as to be accessible. In addition it is preferable not to retain within administrative areas any paper records which may have been in contact with animal rooms. Here, we present a flexible, simple and inexpensive process for the generation and storage of electronic animal husbandry records using smartphone technology over a WiFi or cellular network.
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Bowler, Isobel. "Further Notes on Record Taking and Making in Maternity Care: The Case of South Asian Descent Women." Sociological Review 43, no. 1 (February 1995): 36–51. http://dx.doi.org/10.1111/j.1467-954x.1995.tb02477.x.
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This paper draws on data from a small-scale ethnographic study of the delivery of maternity care to South Asian descent women in a hospital in Southern England during 1988. Stereotyped views of these women which related to their customs and culture as well as their typification as patients were commonly expressed by staff, particularly midwives. The paper examines the role of medical records and record making in stereotyping Asian women: the ways in which stereotyped views of women may affect the record making process; and how that process itself may reinforce and create stereotypes. The utility of records for ‘rate production’ purposes is also discussed. The focus of the paper is the creation of a woman's maternity records which occurs in the antenatal clinic. The transformation of stigmatised views of a client into ‘facts’ about a client is common among bureaucrats, in this setting health service staff. This process affects the client's future encounters with the bureaucracy. In medical settings records (ie the case notes) help to create, transmit and reify negative stereotypes of health service users. These stereotypes can affect the kind of care given to individual patients.
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Park, Hyun-A. "The Study on Health Information Characteristics and Privacy." Journal of Medical Imaging and Health Informatics 10, no. 11 (November 1, 2020): 2543–50. http://dx.doi.org/10.1166/jmihi.2020.3267.
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Because health information has some different properties from other general data, it is important to understand 'information subject,' 'subject of information generation,' 'subject of information management' according to the characteristics of each medical information. It makes it possible to develop the appropriate security technology under the current legal regulations. In this paper, we identify some incorrect uses in existing papers, we show that "Patient-Participated on Electronic Health Record Systems" is more appropriate expression rather than "Patient-Controlled on Electronic Health Record Systems." We discuss three key factors (information subject, subject of information generation, subject of information management) of medical information and 'personal information self-determination.' As a solution for privacy, we suggest the 'Secure and dynamic consent system' and 'Personally-controlled health record on PHR (Personal Health Records)' should be developed under the current law and the current (or future) integrated medical information system.
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Park, Hyun-A. "The Study on Health Information Characteristics and Privacy." Journal of Medical Imaging and Health Informatics 10, no. 11 (November 1, 2020): 2543–50. http://dx.doi.org/10.1166/jmihi.2020.32672543.
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Because health information has some different properties from other general data, it is important to understand 'information subject,' 'subject of information generation,' 'subject of information management' according to the characteristics of each medical information. It makes it possible to develop the appropriate security technology under the current legal regulations. In this paper, we identify some incorrect uses in existing papers, we show that "Patient-Participated on Electronic Health Record Systems" is more appropriate expression rather than "Patient-Controlled on Electronic Health Record Systems." We discuss three key factors (information subject, subject of information generation, subject of information management) of medical information and 'personal information self-determination.' As a solution for privacy, we suggest the 'Secure and dynamic consent system' and 'Personally-controlled health record on PHR (Personal Health Records)' should be developed under the current law and the current (or future) integrated medical information system.
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Devkota, Bishnu, B. Reichart, E. Armbrecht, and J. Smith. "Diabetes care quality indicators improve upon conversion to electronic health records." Health Renaissance 11, no. 1 (February 10, 2013): 27–32. http://dx.doi.org/10.3126/hren.v11i1.7598.
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Introduction: Electronic medical record (EMR) systems have been touted to improve quality and reduce cost of health care delivery. Objectives: To find out whether electronic health record is better than the paper medical records in recording the quality metrics for management of diabetes. Methods: We tested purported benefits in an academic primary care setting with a pilot of 50 randomly selected subjects with Type 2 diabetes with under continuous care by internists before and after EMR implementation. In comparison to the paper chart period, EMR was associated with better outcomes for glycated hemoglobin (A1C), blood pressure (BP), and smoking cessation counseling documentation using a paired analysis technique.Results: Goal BP (130/80) was achieved for 65% of patients during the paper chart period versus 88% in the EMR period (p = 0.007); mean A1c was 7.60 in the paper chart period versus 7.24 in EMR (p = 0.004); smoking cessation documentation rose from 30% to 84% (p < 0.001) between the paper chart and EMR periods, respectively. Change in mean LDL was not statistically significant (p = 0.636) between the two periods. Conclusion: This pilot study provides a favorable indication that EMR implementation contributes to clinical quality improvement and it also illustrates a feasible applied research method that can be employed by many provider organizations who are called up to conduct continuous quality improvement projects for diabetes care. Health Renaissance, January-April 2013; Vol. 11 No.1; 27-32 DOI: http://dx.doi.org/10.3126/hren.v11i1.7598
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Lavariega, Juan C., Roberto Garza, Lorena G. Gómez, Victor J. Lara-Diaz, and Manuel J. Silva-Cavazos. "EEMI - An Electronic Health Record for Pediatricians." International Journal of Healthcare Information Systems and Informatics 11, no. 3 (July 2016): 57–69. http://dx.doi.org/10.4018/ijhisi.2016070104.
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The use of paper health records and handwritten prescriptions are prone to preset errors of misunderstanding instructions or interpretations that derive in affecting patients' health. Electronic Health Records (EHR) systems are useful tools that among other functions can assists physicians' tasks such as finding recommended medicines, their contraindications, and dosage for a given diagnosis, filling prescriptions and support data sharing with other systems. This paper presents EEMI, a Children EHR focused on assisting pediatricians in their daily office practice. EEMI functionality keeps the relationships among diagnosis, treatment, and medications. EEMI also calculates dosages and automatically creates prescriptions which can be personalized by the physician. The system also validates patient allergies. This paper also presents the current use of EHRs in Mexico, the Mexican Norm (NOM-024-SSA3-2010), standards for the development of electronic medical records and its relationships with other standards for data exchange and data representation in the health area.