Ensuring The Integrity Of Electronic Health Records

Data integrity is a critical aspect to the design, implementation, and usage of any system which stores, processes, or retrieves data. The overall intent of any data integrity technique is the same: ensure data is recorded exactly as intended and, upon later retrieval, ensure the data is the same as it was when originally recorded. Any alternation to the data is then traced to the person who made the modification. The integrity of data in a patient’s electronic health record is critical to ensuring the safety of the patient. This book is relevant to production systems and quality control systems associated with the manufacture of pharmaceuticals and medical device products and updates the practical information to enable better understanding of the controls applicable to e-records. The book highlights the e-records suitability implementation and associated risk-assessed controls, and e-records handling. The book also provides updated regulatory standards from global regulatory organizations such as MHRA, Medicines and Healthcare Products Regulatory Agency (UK); FDA, Food and Drug Administration (US); National Medical Products Association (China); TGA, Therapeutic Goods Administration (Australia); SIMGP, Russia State Institute of Medicines and Good Practices; and the World Health Organization, to name a few.

When you visit the doctor, information about you may be recorded in an office computer. Your tests may be sent to a laboratory or consulting physician. Relevant information may be transmitted to your health insurer or pharmacy. Your data may be collected by the state government or by an organization that accredits health care or studies medical costs. By making information more readily available to those who need it, greater use of computerized health information can help improve the quality of health care and reduce its costs. Yet health care organizations must find ways to ensure that electronic health information is not improperly divulged. Patient privacy has been an issue since the oath of Hippocrates first called on physicians to "keep silence" on patient matters, and with highly sensitive dataâ€"genetic information, HIV test results, psychiatric recordsâ€"entering patient records, concerns over privacy and security are growing. For the Record responds to the health care industry's need for greater guidance in protecting health information that increasingly flows through the national information infrastructureâ€"from patient to provider, payer, analyst, employer, government agency, medical product manufacturer, and beyond. This book makes practical detailed recommendations for technical and organizational solutions and national-level initiatives. For the Record describes two major types of privacy and security concerns that stem from the availability of health information in electronic form: the increased potential for inappropriate release of information held by individual organizations (whether by those with access to computerized records or those who break into them) and systemic concerns derived from open and widespread sharing of data among various parties. The committee reports on the technological and organizational aspects of security management, including basic principles of security; the effectiveness of technologies for user authentication, access control, and encryption; obstacles and incentives in the adoption of new technologies; and mechanisms for training, monitoring, and enforcement. For the Record reviews the growing interest in electronic medical records; the increasing value of health information to providers, payers, researchers, and administrators; and the current legal and regulatory environment for protecting health data. This information is of immediate interest to policymakers, health policy researchers, patient advocates, professionals in health data management, and other stakeholders.

This book details how electronic health records (EHRs) and medical records (EMRs) can be optimized to enable meaningful interactions between provider and patient to enhance quality of care in this new era of mHealth. As the technologies evolve to provide greater opportunities for mHealth applications, so do the challenges. This book addresses the issues of interoperability limitations, data processing errors and patient data privacy while providing instruction on how blockchain-like processes can potentially ensure the integrity of an externally maintained EHR. Portable Health Records in a Mobile Society identifies important issues and promising solutions to create a truly portable EHRs. It is a valuable resource for all informaticians and healthcare providers seeking an up-to-date resource on how to improve the availability, reliability, integrity and sustainability of these revolutionary developments in healthcare management.

This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

This book details how electronic health records (EHRs) and medical records (EMRs) can be optimized to enable meaningful interactions between provider and patient to enhance quality of care in this new era of mHealth. As the technologies evolve to provide greater opportunities for mHealth applications, so do the challenges. This book addresses the issues of interoperability limitations, data processing errors and patient data privacy while providing instruction on how blockchain-like processes can potentially ensure the integrity of an externally maintained EHR. Portable Health Records in a Mobile Society identifies important issues and promising solutions to create a truly portable EHRs. It is a valuable resource for all informaticians and healthcare providers seeking an up-to-date resource on how to improve the availability, reliability, integrity and sustainability of these revolutionary developments in healthcare management. .

This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable results that cannot be replicated. Even randomized controlled trials (RCTs), the traditional gold standards of the research reliability hierarchy, are not without limitations. They can be costly, labor intensive, and slow, and can return results that are seldom generalizable to every patient population. Furthermore, many pertinent but unresolved clinical and medical systems issues do not seem to have attracted the interest of the research enterprise, which has come to focus instead on cellular and molecular investigations and single-agent (e.g., a drug or device) effects. For clinicians, the end result is a bit of a “data desert” when it comes to making decisions. The new research infrastructure proposed in this book will help the medical profession to make ethically sound and well informed decisions for their patients.

Determinants of health - like physical activity levels and living conditions - have traditionally been the concern of public health and have not been linked closely to clinical practice. However, if standardized social and behavioral data can be incorporated into patient electronic health records (EHRs), those data can provide crucial information about factors that influence health and the effectiveness of treatment. Such information is useful for diagnosis, treatment choices, policy, health care system design, and innovations to improve health outcomes and reduce health care costs. Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 identifies domains and measures that capture the social determinants of health to inform the development of recommendations for the meaningful use of EHRs. This report is the second part of a two-part study. The Phase 1 report identified 17 domains for inclusion in EHRs. This report pinpoints 12 measures related to 11 of the initial domains and considers the implications of incorporating them into all EHRs. This book includes three chapters from the Phase 1 report in addition to the new Phase 2 material. Standardized use of EHRs that include social and behavioral domains could provide better patient care, improve population health, and enable more informative research. The recommendations of Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 will provide valuable information on which to base problem identification, clinical diagnoses, patient treatment, outcomes assessment, and population health measurement.