Melinda Helton – 705778
Data Analytics and Information Governance – C803, Task 3
Health records are vital for health organizations because with the health records, it is straightforward for any health organization to get to know the data of the patients, medicine and the machines that are available in the health organization (Mangalmurti et al., 2010). An adequate health record will enable smooth flow of the work in the health organization. For instance, when the records are streamlined, patients will be attended to effectively because the health management will be able to allocate resources that will be enough for the available patients. Further, effective records will ensure that the available resources are effectively used because they will be having the number of patients and the drug stock records as they allocate money for the needs. Health records come in different ways; there are paper health records, hybrid health records, and the electronic health records.
Characteristics of Types of Records
There are some distinctive characteristics of different types of health records. To begin with paper health records, despite the coming of electronic health records and hybrid health records, paper health records are not yet fully eliminated. Some of the characteristics of paper records include reliability (Mangalmurti et al., 2010). The paper records are very reliable since they are handwritten and a person can easily be accountable for his or her handwriting. This helps in the accountability, for instance, if there is a problem with the records, it is very easy for a person to account for the error, unlike the electronic health record in which the accountability is tough. Another characteristic of the paper record is that it is very cheap and the management is very easy. For example, the organization only needs to purchase pens and records books.
On the other hand, hybrid health record gets noted as individual health information that is kept in the multiple places. Hybrid heath record is the most efficient so far because it combines the use of both paper and electronic health records. Some of the characteristics of hybrid health records include maximum safety of the records. Because the information about the records can be gotten from both sides, that is from the paper and electronic format. It is challenging for the data to get lost at once. If data from one source is lost, at least there is hope of getting the data from the other sources in which the same information is stored. Another characteristic is that it is easier to retrieve data from the data in the hybrid records are arranged in chronological order (Mangalmurti et al., 2010). The third characteristic is that the hybrid health record is adjustable; it is flexible for any changes that may occur on the data in the future. For instance, if there were eighty patients and ten patients sign off, it is very easy for the records to be adjusted automatically without any constraints.
In contrast, electronic health records have got the following characteristics. First, electronic health records incorporate the use of software to manage the record in the health organization. It is a completely incorporated system that allows for administration of information about the patients as well as the information about the resources that are in the health organization. Secondly, it provides for PQRI automation. The PQRI reports the physician quality reporting initiative. Lastly, are the effective documentation and the effective image of the management (Mangalmurti et al., 2010). This makes it possible for the health organization to keep the information and the data in an organized manner that can easily be retrieved.
Despite being used by so many organizations today in the United States, there are some legal issues that may arise when using hybrid health records. First, there is the likelihood of medical errors. Despite the improvement of the health records system, there are some errors that are likely to occur while using the hybrid health records. For instance, because, all the commands are happening just by a click of the button or a mouse, it is very easy for an expert to command the unwanted information that may bring about a total error in the records. Being that it involves both the paper and the electronic health records, if a mistake is made in one form, then the same error will be carried to the other record method.
Secondly, there are breaches, theft and unauthorized access; there are still some fraud claims that may come as a result of the use of hybrid health record. For instance, there is a possibility that a person can enter the system and cause changes that may, in turn, affect the organization of the data in the system. Further, someone may generate a logarithm that may cause auto multiplication of the data and as a result, may affect the effectiveness of the hybrid record system. The unauthorized intruder may affect the data that are in the system very adversely.
Another legal issue that is related to the hybrid health records is the security of the data. The confidentiality of the data is very essential when it comes to the record keeping. As a physician, it is essential to ensure that the privacy of the records is maintained. Hybrid health records despite being very secure; some cases have been reported in which the security of the data has been jeopardized.
I am a resident of Ohio. The retention, storing and destruction of the patient records according to the Ohio medical department occur procedurally just as it is depicted in the Cedar Bend Record policy. I, in this case, believe that my state’s regulation complies with the Cedar Bend Record policy. In Ohio State, the records are retained for five years, failure to appear, the record will be destroyed. Master, patient index records, are permanently stored. However, the only difference that exists between our states regulations and the Cedar Bend Hospital Guidelines is the adult medical records which are five years maximum in our state while it is ten years in the Cedar Bend Hospital guidelines. All other guidelines of Cedar Bend Hospital are in the line of our state’s guidelines (Hsiao & Hing, 2012).
Medicare Conditions of Participation
In comparison with the Medicare conditions of participation, I can note that Cedar Bend record policies are in line with the Medicare conditions of participation (Centers for Medicare & Medicaid Services, 2007). First, there is a law that requires all the hospitals to retain the records, maintain them and destroy them at a given time. The major reasons as to why I believe that there is a correlation between the Cedar Bend record policy and Medicare conditions of participation is first, the federal record retention requirements as indicated in the Medicare Conditions of participation is in line with the record policies that have been outlined by Cedar Bend hospital. There are however little differences because of the health laws that govern every state. I, therefore, concur that Cedar Bend Hospital is in line with the Medicare conditions of participation.
Health Insurance Portability and Accountability Act (HIPAA) Security Rules were established to help in the management of the health records. There are so many rules regarding the recording and retention of the patient’s records (O’herrin & Kudsk, 2004). However, the section 164.316 outlines the documentation requirements. These requirements include, the procures and policies, it is stated that when formulating plans, it is essential that the health organization focuses on the standard procedures that are outlined in the health guidelines when they are coming with policies. According to the plans made by Cedar Bend hospital, I can concur that Cedar Bend hospital complies with the Health Insurance Portability and Accountability Act (HIPAA) Security Rules.
Centers for Medicare & Medicaid Services (CMS), HHS. (2007). Medicare program; hospital conditions of participation: requirements for approval and re-approval of transplant centers to perform organ transplants. Final rule. Federal register, 72(61), 15197. https://www.ncbi.nlm.nih.gov/pubmed/17450666Hsiao, C. J., & Hing, E. (2012). Use and characteristics of electronic health record systems among office-based physician practices, United States, 2001-2012. https://pdfs.semanticscholar.org/9db7/4d0d8c465debc027e754b7b9625b73b5dceb.pdfMangalmurti, S. S., Murtagh, L., & Mello, M. M. (2010). Medical malpractice liability in the age of electronic health records. https://www.nejm.org/doi/full/10.1056/NEJMhle1005210O’herrin, J. K., Fost, N., ; Kudsk, K. A. (2004). Health Insurance Portability Accountability Act (HIPAA) regulations: effect on medical record research. Annals of surgery, 239(6), 772. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356285/