The Pros And Cons Of Electronic Health Records

Until recently paper charting has been the standard. From registration and consent for treatment to physician and nurses progress notes. A request for medical records would take an extended period of time as the chart had to be located and then pulled apart for copies to be made and sent to the requesting party. In Emergency situations sharing medical information was cumbersome and again the chart would have to be pulled in order to share the information. With the inception of Electronic Health Records, the hope was an increase in documentation standards compared to paper health records, this was not the case. With electronic health records patient safety and documentation quality increased. As the electronic health record continued to grow

North Coast Clinics Network is a Direct Exchange, this exchange links a multiple clinic and specialty practices that are all owned and operated under the same cooperation, Open Door Community Health Centers. This cooperation has multiple locations varying from primary care physicians, mobile medical care to specialties such as dental and orthodontia. North Coast Health Information Network is also a Direct Exchange however the information is limited. A direct link to two hospitals (the only in this area) to obtain laboratory testing results only. There are multiple providers linked to this access however with the limited information available it is not as useful as I imagine it could be.

Clinical terminology and data standards are key to the success of Health Information Exchange. The same language must be spoken in order to communicate. Facilities or health care providers can have different operating systems that cannot normally work with other systems however if they spoke the same language the exchange or sharing of information would be seamless. Following the same set of data standards ensures the information gathered and shared will be meaningful and useful to another provider or

Whether providing point of service care or filling a prescription the quality of the data received and shared is vital. The accuracy of data within the health record to support the patient’s care versus diagnosis and validity of charges to be submitted to an insurance carrier is supported by the relevance and comprehensiveness of data collected during a patient encounter. Relevant data is collected (according to the facility specific definition and granularity) to provide current and accurate health information. The secure accessibility of the health record to allow nursing notes and physician orders to be updated. The precision and timeliness of entered information is watched carefully to verify patient care is being documented in real time. (Nguyen MD, V)

“The success… depends on consumer confidence in its privacy and security, HIE business practices must be unambiguous and transparent to the public. Without consumer buy-in the… will fail” (Rhodes, 2006) This article was powerful and very insightful. There are many challenges associated with sharing information, privacy, confidentiality and security are of the utmost concern. A successful HIE should include collection limitations, use limitations, data integrity, security controls and safeguards as well as the oversight and accountability required to ensure the confidentiality and privacy of patient