Authentication is a certificate that something, such as a medical record, is genuine. The purpose of authentication is to prove authorship and attribute responsibility for an action, event, condition, opinion, or diagnosis.3 Each entry in the medical record must be authenticated and traceable to the author of the entry. The rules of proof indicate that only the author of the entry is aware of the entry. The Federal Regulations and Interpretation Guidelines for Hospitals (482.24(c)(1)(i)) require that there be a method to determine whether the author has effectively authenticated the entry.4 This process should be defined in HIM`s written policies and procedures and support the authentication of an entry in a legal process. A key unresolved financial question is who should pay for the implementation and use of EHRs and SIIs. Under most current reimbursement models for providers, it is estimated that 89% of the financial benefits of using EHRs go to health care payers rather than those currently funding the implementation of EHRs.59 In addition, the use of EHRs can potentially reduce the productivity of individual providers by 10%.60 Physicians are naturally concerned about the costs and resources required to implement and the maintenance of EHRs. estimated to be between $40,000 and $50,000.61 While the federal stimulus package helps reimburse some of these costs to clinicians, questions remain about the role of private health insurers in funding the implementation of EHRs and HIAs, with private insurers being among their main beneficiaries.62 Conversely, the recent passage of the Patient Protection and Affordable Care Act with its responsible care organizations63 and the focus on the patient-centred medical home model64 Promise of increased financial support for the implementation of EHRs and HIA. Where state, federal, and refund regulations permit, electronic signatures are allowed as authentication. Electronic signature technology should be used to verify the identity of the author.5 Medical record: a record that identifies the patient and documents the patient`s diagnosis and care. Second, EHRs can increase clinicians` legal accountability and accountability.19 Sophisticated computerized audit procedures,20 Unlike paper-based radiation protocols, can identify individuals who review or fail to verify important information in the EHR.21 Consider the scenario in which an abnormal finding is documented in the EHR and then reviewed by multiple clinicians, but never treated. While it is not always easy in paper files to tell who accessed this information, an EHR audit log easily shows evidence of this error. Similarly, warnings for abnormal test results can be considered, but not implemented, on the assumption that another clinician was responsible.22 While some of these issues have not yet gained prominence in the justice system, these issues are becoming more pressing as the country`s health information network becomes available online and large amounts of patient data become accessible.
to more and more clinicians.23 Electronic signature: A technology that uses a unique personal identification number, electronic identification, or biometric scans to sign an electronic document. Subpoena duces tecum: a written order directing a person to appear, testify and bring all documents, papers, books and records described in the subpoena. The devices are used to obtain documents during the pre-trial discovery and testimonies during the trial. In the past, medical records were considered hearsay and inadmissible in court proceedings. However, the Federal Rules of Evidence and the Uniform Rules of Evidence have codified the hearsay rule exception for commercial records, allowing for the use of health records in court.6 Information such as data published by nursing stations for patient transfers must be generated from published features of the electronic software and must not include screen prints. Risk Management: Monitor medical, legal, and administrative processes within a healthcare organization to minimize its risk of liability. In the past, the statutory health record was just the content of a paper diagram, but as more healthcare facilities adopt electronic health records (EHRs) and use health applications for patient monitoring and data tracking on various forms of electronic media, defining and creating a legal health record is becoming increasingly complex. Security measures such as firewalls, antivirus software, and intrusion detection software should be included to protect data integrity.
Specific policies and procedures are designed to protect patient privacy and confidentiality. For example, employees are not allowed to share their ID with third parties, always log out when they leave a device, and access digital patient records with their own ID. A security officer must be appointed by the organization to work with a team of healthcare IT professionals. While it is important to control access to health information, it is not enough to protect confidentiality. Additional security measures such as strict privacy and security policies are essential to protect patient information. In summary, key legal, ethical and financial issues need to be addressed if better and cheaper healthcare is to be achieved through the widespread use of EHEA. A series of conversations, culminating in a national forum involving patients, lawyers, ethicists, economists, policy makers, computer scientists and clinicians, all of whom are very committed to these issues, must begin now. The objective of these discussions should be to identify and prioritize solutions to the main legal, ethical and financial issues addressed in this commentary. The Office of the National Health Information Technology (IT) Coordinator calls the health record « not just a collection of data you protect, it`s life. » [7] The patient has the information in the file.