Confidentiality, Consent and Autonomy in the Physician-Patient Relationship

In the practice of medicine there has long been a conflict between patient management and respect for patient autonomy. In recent years this conflict has taken on a new form as patient management has increasingly been shifted from physicians to insurers, employers, and health care bureaucracies. The consequence has been a diminshment of both physician and patient autonomy and a parallel diminishment of medical record confidentiality. Although the new managers pay lip service to the rights of patients to confidentiality of their records, in fact they advocate very liberal medical records access policies. They argue that a wide range of parties has a need to know the contents of individually identifiable medical records in order to control costs, promote quality of care, and undertake research in the public interest. Broad interpretations of the need to know, however, are at odds with strict interpretations of the right to confidentiality. Strict confidentiality policies require that, with few exceptions, patient consent be obtained whenever a patient's record is used outside the treatment context. The traditional criterion for overriding the consent requirement has been that without the override some harm would directly result. This rule is now challenged by the claim that patients have a duty to make their records available for a wide range of research and public health purposes. The longstanding tension between physician responsibility for patient welfare and respect for patient autonomy is being replaced by a debatable requirement that both physician and patient autonomy be subordinated to the goals of data collection and analysis. This revised version was published online in July 2006 with corrections to the Cover Date.     

American Health Information Management Association. Position statement. Issue: healthcare reform--information systems and the need for computer-based patient records

Timely, reliable information is a critical part of healthcare reform. The Clinton Administration's current proposal would streamline health information through the use of standard forms and data definitions and establish a nationwide electronic highway to link health records and exchange needed information. Information would be captured, retained, and transmitted as a routine byproduct of patient care. These goals can be achieved only through broad implementation of the computer-based patient record (CPR). The CPR will contribute to more effective and cost-efficient care through (1) ready access to longitudinal (lifetime) health information; (2) support for continuous quality improvement; (3) easy access to clinical knowledge bases; and (4) patient participation in health documentation and disease prevention. The technology exists to implement the CPR, but further work is needed to develop the necessary standards and security mechanisms. The American Health Information Management Association is committed to working with applicable state and federal agencies, professional associations, accrediting agencies, voluntary standards organizations, and the Computer-Based Patient Record Institute (CPRI) to achieve the information management objectives of the current health care reform plan. With their expertise in health information systems and strong commitment to patient privacy, health information management professionals can make significant contributions to the development, implementation, and ongoing security of national and state health information networks.     

Electronic medical record systems as a basis for computer-based patient records

In summation, some document imaging systems offer the capability to form what may be called electronic medical record (EMR) systems. These systems are adaptations of current paper-based record management systems into the digital environment, but they offer far more capabilities than strictly archival, historical functions. Some of the capabilities that create EMR systems will also be necessary for development of CPRs, these capabilities are listed as follows: mass storage and image management; direct capture, storage, and retrieval of digital information (native format); large volume, high-speed, client-server networks; multi-media information management; high-power, flexible database tools; workflow process software; flexible, full function security; user customizable features; and alerts and reminders. Selection and implementation of document imaging systems should, at present, be undertaken with great care to insure that the platform may be utilized to form an electronic medical record with a clear migration path to the CPR.     

A practical approach to medical records in a rural health care setting.

Deciding on a system for keeping medical records in a new rural health practice, or in an established practice seeking to update an obsolete system, may be confusing because of a multitude of vendors who claim to meet every need. Special circumstances set rural practices apart from other ambulatory care settings with regard to medical record needs. Practical consideration regarding filing systems, record content and format are offered in view of these special circumstances. Issues involving ownership of the record and access to confidential information are also explored.     

The emerging need for transformational leadership in health information management

The prospect of national healthcare reform, new clinical and information technologies, and the need to cut the cost of health care delivery are contributing factors in the restructuring of the health care system. In light of these rapid changes and great uncertainties, health information management (HIM) leadership must radically change its style. The appropriate new styles will move the HIM practitioner from the specialized medical records department to a larger, more professional role. The successful transformational leader will help HIM emerge as a central function in the new health care industries.     

Creating an infrastructure for the productive sharing of clinical information

The need for a patient-centered approach to health care services delivery is well recognized. Health care has become more specialized, with increasing numbers of disciplines and subdisciplines. In addition, both providers and community are increasingly mobile. As a consequence, patients see more providers, which has led to increasing fragmentation of patient-centered care and in particular of patients' personal health records. Clinicians and patients alike recognize the need to ensure that care information is patient-centered, continuous, and integrated in order to optimize the effectiveness of proactive and reactive care. Current arrangements, however, including the architecture of medical record and information management systems, are mainly provider- and service-centered and may not readily support the sharing of data to this end.     

Building a patient record system. New information technologies will support development of patient-focused care

As part of its plan to build a regional integrated healthcare delivery network, Genesys Health System, Flint, MI, has been developing a computerized patient record (CPR). The CPR will give users throughout the system immediate access to diagnostic studies, treatment information, discharge summaries, operative reports, x-rays, and other patient information. Before considering technical aspects of the system, healthcare executives considering implementation of a CPR should examine business and clinical issues to determine what they want to accomplish with the CPR. The Genesys information system is being designed with the following goals in mind: Organizing based on patient needs; Allocating resources at the point of care; Working as a broadly skilled, empowered staff; Delegating authority and accountability; Using technology to enable patient-focused care within the context of the system vision. Genesys envisions a CPR system that brings together records from such sources as emergency rooms, outpatient clinics, community service organizations, physicians offices, care teams, managed care companies, and financial systems. Genesys's use of care plans for specified procedures and diagnoses will enable it to use exception-based documentation of care delivered, whereby only departures from the protocol or unexpected outcomes are recorded.     

The reformation of information technology

During the last twenty years there have been major changes in European health services in the need for information, technology and the information user. The need for information for management purposes has been highlighted by the shift away from running institutions to providing health care for defined populations, and the diminution in financial growth available to health services. To provide comprehensive care in the current financial climate there is a requirement for relevant and timely information about the patients being treated, the population from which they come and the cost and effectiveness of the treatment being provided. Major changes have occurred in both the software and hardware available for information technology (IT) applications. Modern technology cannot only process statistical data but also acquire, process, store and disseminate vocal, pictorial, textual and numerical information. Among applications of interest to health service managers are quantitative data systems, planning systems, text management systems and communications both within the organization and with other organisations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Electronic medical records and health care transformation

Effective electronic medical care record (EMR) systems will make a critical contribution to health care transformation. However, we need to know more about the total costs of EMRs and the ways in which they will interact with existing health care systems to make compelling predictions about their clinical benefits or the savings they can enable.     

Health care-oriented telecommunications: the wave of the future

This article has examined the impact that telecommunications technologies may have on the way in which health care services are delivered. A number of scenarios of how that might occur were discussed. Some of these scenarios are already being realized. Telemedicine, for instance, is being used in certain geographic regions of the United States. Various community health information networks are in the developmental stages or at varying degrees of operability. Two such networks in Colorado and Wisconsin were offered as examples. The impact of these developments on confidentiality and security of patient information, issues central to the responsibilities of health information managers, has been discussed. These technological advancements will have consequences for health information managers in other ways, too. The types of tasks that are performed and how those tasks are performed related to storing and retrieving information will be different in the future. In the transition period, blurring of job functions may occur as different types of practitioners strive to carve their niche in the electronic environment. For instance, as electronic patient records are linked to bibliographic databases of medical literature, where do the responsibilities of health information managers end and medical librarians begin? The best way to ensure a position on the health care team of the future is to recognize the opportunities provided by this dynamic period in health care.     

Providers' reactions to an automated health maintenance reminder system incorporated into the patient's electronic medical record

BACKGROUND: Automated health maintenance reminder (HMR) systems embedded in electronic medical records systems have been found to improve utilization of preventive services, but underuse persists. Our goal was to learn how to make HMRs more effective by measuring clinicians' self-reported use of HMRs and attitudes toward an HMR system embedded in an electronic medical record. METHODS: We surveyed 43 clinicians using an electronic medical record with an automated HMR system that prompted the provision of preventive or screening interventions. We measured general attitudes toward computers and the HMR, attitudes toward health maintenance, reactions to key features of the HMR system, and use of information provided by the HMR system; and we asked open-ended responses on how to improve the system. RESULTS: Seventy-five percent of clinicians reported not observing or paying attention to the HMR flashing reminder icon when reviewing a chart, and 62.8% reported they either ignored or forgot to address an alert when it appeared. Only 20% reported regularly reviewing health maintenance needs of the patient before the clinical encounter, and 56% reported seldom or never acting on HMR information during an encounter that was not health maintenance. CONCLUSIONS: This HMR system embedded in an electronic medical record was underused by clinicians, causing lost opportunities for provision of preventive care. As electronic medical records become more common, we need to find practical ways that are acceptable to clinicians to use the new capabilities the systems provide.     

Social work management in emerging health care systems

An overview of the health care industry's trend toward multihealth systems is presented and specific adaptive strategies for social work managers in health care are suggested. The challenges to social work leaders during this transition from largely free-standing, privately owned health care institutions to corporately owned, horizontally and vertically integrated delivery systems are discussed in terms of identity, style, and substance. Directors of social work departments in multihealth corporations will need to resolve issues of institutional versus corporate identity as well as those of corporate versus professional identity. A multioptional management style that incorporates networking and political expertise should be cultivated. Substantive demands in the areas of management information systems, productivity, quality assurance, and budgeting also must be addressed. The emergence of multihealth systems poses major challenges and unique opportunities to the social work profession. Awareness of managerial strategies and critical content areas can help social work leaders enhance the role and contribution of social work in these exciting and complex health care delivery systems.     

Keeping health promotion in the pink. Documentation can show how programs contribute to hospital goals

Health promotion encompasses a wide range of services, including health information, health education, wellness, and employee health programs--important efforts, but hardly life-or-death matters. So with increased pressure to put programs to an institutional "worth" test, few health promotion programs make the grade, not because they fail, but because their managers do not know how to document and demonstrate their contributions to hospital goals. The tools that can be used to track program impact range from simple hand-written record keeping on file cards to more complicated and computer-supported systems of data gathering and analysis. It is a mistake to assume that only computer-based systems can yield meaningful information. In the documentation process it may be necessary to start small, but it is necessary to start. Sound management decisions depend on practical evidence that a program is helping a hospital's operations. When one hospital implemented an employee assistance program, program managers set out to document how the program saved the hospital money, improved the work environment, and improved quality of care. At another hospital, the manager of the inpatient cardiac rehabilitation program enlisted the assistance of the medical records department to document to the hospital that patients not in the program had longer lengths of stay than program participants.     

Health information management using optical storage technology: case studies

All the health care facilities examined in the case studies addressed several important organizational issues before and during the installation of their systems. All the facilities examined employee commitment. The prudent managers considered how easily their employees adapt to changes in their jobs and work environment. They considered how enthusiastic cooperation can be fostered in the creation of a liberated and reengineered office. This was determined not only by each individual's reaction to change, but also by the health care facility's track record with other system installations. For example, document image, diagnostic image, and coded data processing systems allow the integration of divergent health care information systems within complex institutions. Unfortunately, many institutions are currently struggling with how to create an information management architecture that will integrate their mature systems, such as their patient care and financial systems. Information managers must realize that if optical storage technology-based systems are used in a strategic and planned fashion, these systems can act as focal points for systems integration, not as promises to further confuse the issue. Another issue that needed attention in all the examples was the work environment. The managers considered how the work environment was going to affect the ability to integrate optical image and data systems into the institution. For example, many of these medical centers have created alliances with clinics, HMOs, and large corporate users of medical services. This created a demand for all or part of the health information outside the confines of the original institution. Since the work environment is composed of a handful of factors such as merged medical services, as many work environment factors as possible were addressed before application of the optical storage technology solution in the institutions. And finally, the third critical issue was the organization of work. "Organizations that understand their business processes are having no trouble whatsoever justifying the cost of optical storage-based information management systems," said Thornton May, director of imaging research at Nolan Norton Institute. "It is only confusing to organizations that do not have a feel for what is happening in the flow of work in the company. If an organization has on-line performance measurements with regard to time, cost, quality, error rates, and customer service, the move to optical image and data management technology is a no-brainer."(ABSTRACT TRUNCATED AT 400 WORDS)     

居家养老电子健康档案管理体系构建

居家养老医疗照护需要电子健康档案为医疗活动提供准确的数据支持。文章从居家养老电子档案的主要内容、体系架构及功能、信息系统界面设计、数据采集及管理方案等方面介绍了体系架构,并介绍了居家养老电子健康档案的应用情况,为完善我国居民电子健康档案管理提供参考。     

提高病案首页数据采集质量

病案首页是医院质量管理的重要原始资料。对影响病案首页数据采集质量的因素从人员与管理两方面进行了分析,指出通过加强培训,提高医务人员数据采集质量意识;依托病案全程动态质量监控网络,加强数据源管理;调动医务人员参与信息管理的积极性等措施,可有效提高病案首页数据采集质量。     

谈新形势下军队医院病案管理

军队医院病案管理者需增强法律责任意识,制定病案管理细则,提高病案管理工作质量,改变病案管理人员的工作态度和观念,更好地完成病案管理,使病案信息全面地为社会服务。     

The electronic medical record: a definition and discussion

The health care industry has had limited success in achieving some degree of an EMR in the past several years, and the industry has the potential to move even farther in the next decade. As standards begin to emerge and technologies conform to those standards, the industry will begin to see the evolution of a totally electronic patient record. Standard interfaces and hardware platforms, with software products designed to meet a standardized market need, will become more prevalent. Multifunction workstations, voice recognition, and other technological advancements will simplify the data-entry process for clinicians. Legal statutes that support automated records will be established and accepted by the courts, and optical disk image processing systems will take off as the storage medium of choice for the next generation. Because the EMR can provide the benefits outlined here, the health care industry must work together to ensure the success of this vision. As leaders in the health care information management arena, we need to participate in the realization of this ideal for the betterment of our patients, our health care organizations, and the entire health care delivery system.