Electronic Medical Records for (HIPAA) Compliance
Technology promises many important advances in the way the medical industry maintains health records. By introducing new technology and electronic medical records, health-care professionals can prevent medical mistakes, and provide more cost effective record management. Technology improves efficiency and productivity while leading to better health care value. The health care industry has long been at the forefront of technological innovation and this is particularly evidenced by the growth in electronic patient medical records.
There are two types of computerized medical records. The first type of computer medical records are digital images from scanned paper-based medical records in TIFF or PDF formats. The second type is paperless electronic medical record (EMR).
The EMR is the legal record of what happened to the patient during the clinical patient encounter. Included in this information are patient meta data, progress notes, prescriptions, electrocardiogram (EKG) tests, medical history, immunizations, lab results and radiology reports.
The electronic medical record (EMR) is essential for the efficient storage, distribution, and retrieval of patient records in hospitals. An important benefit of EHR is improved workflow as document management software contain built in workflow modules. Workflow modules include manual workflow and rule-based workflow. Manual workflow allows users to view the document and decide who to send it to. Rules-based workflow allows administrators to create rules to direct the flow of the health care through the facility. For instance, approval workflow routes a medical record or data to a group of people for approval.
Hospitals and health care providers still require the old paper-based medical records after the introduction of an EMR software in a hospital. The solution is to scan in existing medical records and charts using OCR can create PDF files that are searchable. Searching is also done by reading the contents, aided by naming conventions of the PDF file name. These searchable files can be stored on secured servers that can be accessed only by those with the proper credentials. This technology is a win for doctors and patients alike.
This new way data management of patient medical records addresses compliance issues with the Health Insurance Portability and Accountability Act, commonly referred to as the HIPAA. This act requires that hospitals and health care providers maintain detailed patient medical records so that health records are accessible and portable.
When information is stored on a computer connected to a network, there are naturally concerns expressed about the security of the patient medical records. Because of these concerns, the HIPAA mandates that precautions must be taken to ensure the security and confidentiality of any medical records stored on the server. This is accomplished by securing both the server and the network from unauthorized individuals.
The HIPAA also requires that health care providers and hospitals must maintain proper records concerning who has access to the medical records as well as information on those who access the records. This helps maintain the confidential nature of patient medical records.
The end result of scanning in the patient medicals, storing them on a secure server, and then tracking access to the records is that patients are able to receive better, more accurate health care while doctors are able to have much more information about the patient’s condition available to him. Everyone in the health care system can benefit from this increased efficiency.
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Medical records for which retention is no longer required should be shredded or otherwise destroyed in accordance with HIPAA guidelines. It is the
responsibility of covered entities to understand the laws as they apply to proper disposal.
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