Nursing informatics

1. By / MahmoudShaqria
‫شقريه‬ ‫محمد‬ ‫محمود‬

2. Learning Objectives :_
 Introduction.
 Define the term computer based patient record.
 Compare and contrast the similarities and
differences between electronic medical record
(EMR) and the computer based record (CBR).
 Understand the Differences between Electronic
health record (HER) and Electronic medical
record (EMR).
 Understand the characteristics of the computer
based patient record.

3.  Discuss the benefits of computer based
patient record.
 Discuss the legal and ethical issues
associated with computer based patient
record.
 Review the important protection of health
care records.

4. Introduction :_
o The patient record is the principal repository
for information concerning a patient's health
care. It affects, in some way, virtually
everyone associated with providing, receiving,
or reimbursing health care services.
o Patient record improvement could make major
contributions to improving the health care
system of this nation.

5. report on automated medical records identified
three major ways in which improved patient
records could benefit health care. First,
automated patient records can improve health
care delivery by providing medical personnel
with better data access, faster data retrieval,
higher quality data, and more versatility in data
display.

6. Automated patient records can also support
decision making and quality assurance activities
and provide clinical reminders to assist in patient
care. Second, automated patient records can
enhance outcomes research programs by
electronically capturing clinical information for
evaluation. Third, automated patient records can
increase hospital efficiency by reducing costs and
improving staff productivity.

7. Define the term (CPR)
 (CPR) is an electronic patient record that
resides in a system specifically designed to
support users by providing accessibility to
complete and accurate data, alerts, reminders,
clinical decision support systems, and other
aids.

8. Compare and contrast the similarities and
differences between (EMR) and (CPR).
1) EMR :-
 (EMRs) are digital versions of the paper charts in
clinician offices, clinics, and hospitals. EMRs
contain notes and information collected by and
for the clinicians in that office, clinic, or hospital
and are mostly used by providers for diagnosis
and treatment.

9.  EMRs are more valuable than paper
records because they enable providers
to track data over time, identify patients
for preventive visits and screenings,
monitor patients, and improve health
care quality.

10.  The EMR usually focuses on a particular
medical specialty, such as neurology. These
records can be made for a department in a
hospital or a group different sites of the
institution, but never between hospitals. of
patients’ medical data from all the
departments at one site of a hospital. These
records usually stay within the group.

11. 2) CPR
 is an electronic patient record that resides in a
system specifically designed to support users
by providing accessibility to complete and
accurate data, alerts, reminders, clinical
decision support systems, and other aids.
 “an electronic record of periodic health care of a
single individual, provided mainly by one
institution.”

12. Differences between EHR and EMR
EMR (electronic medical records)EHR (electronic health record)
A digital version of a chartA digital record of health
information
Not designed to be shared outside
the individual practice
Organized to be shared for
updated, real-time information
Patient record does not easily
travel outside the practice
Allows a patient’s medical
information to move with them
Mainly used by providers for
diagnosis and treatment
Access to tools that providers
can use for decision making

13. Understand the characteristics of the
computer based patient record.
 Accountability
Any access to or modification of a patient's
record should be recorded and visible to the
patient. Thus, data and judgments entered
into the record must be identifiable by their
source. Patients should also be able to see
who has accessed any parts of their record,
under what circumstances, and for what
purpose.

14.  Flexibility
 Computer based patient record data is available
for those who are genuinely trying to improve
medical knowledge, the practice of medicine,
the cost effectiveness of care, and the
education of the next generation of healthcare
providers. Bur, when patients feel the threat of
exploitation, the risk to privacy, or the
annoyance of unsolicited follow up contacts.

15.  Patients should therefore be able to grant or
deny study access to selected personal medical
data.
 Interoperability
 Different computerized medical systems should
be able to share records: they should be able to
accept data (historical, radiological, laboratory,
etc) from multiple sources, including doctors'
offices, hospital computer systems,
laboratories.

16.  Confidentiality
 Patients should have the right to decide who
can examine and alter what part of their
medical records. patient might choose to allow
no access to such records, At the other
extreme some might have no hesitation in
making their records completely public. For
most patients, the appropriate degree of
confidentiality will fall in between and will be a
compromise between privacy and the desire to
receive informed help from medical
practitioners.

17.  access to various parts of the record should
be authorized independently. Most patients
will probably also choose to provide a
confidentiality “override” policy that would
allow an authenticated healthcare provider in
an emergency to gain access to records that
he or she would not normally be able to
access.

18.  Accessibility
 Medical records may be needed on patient's
usual place of care or far from home. They
may be needed when the patient can consent
to their use or when is unconscious. So these
records should be accessible to and usable by
researchers and public health authorities.

19.  Comprehensiveness
 Because care is normally provided to a patient
by different doctors, nurses, pharmacists, and
ancillary providers, and by different institutions
in different geographical areas.

20. Discuss the benefits of the computer
based patient record
 Providing accurate, up-to-date, and complete
information about patients at the point of care
 Enabling quick access to patient records for
more coordinated, efficient care. CPR may
also be accessible from distant locations
e.g. a physician dialing in to the hospital
information system from his/her office or home

21.  Portable, comprehensive personal health
records
 Securely sharing electronic information with
patients and other clinicians
 Helping providers more effectively diagnose
patients, reduce medical errors, and provide
safer care
 Improving patient and provider interaction and
communication, as well as health care
convenience

22.  Enabling safer, more reliable prescribing
 Helping promote legible, complete
documentation and accurate, streamlined
coding and billing
 Enhancing privacy and security of patient data,
Security and privacy protocols not possible in a
paper-based system
 Helping providers improve productivity and
work-life balance
 Enabling providers to improve efficiency and
meet their business goals

23.  Reducing costs through decreased paperwork,
improved safety, reduced duplication of testing,
and improved health.
 Legibility: documentation in a CPR is more
legible because it is recorded as printed text
rather than as hand writing, and it is better
organized
 Variety of views on data: data can be displayed in
many different formats e.g. laboratory data can
be displayed as numerical figures or graphical
representation

24.  help clinical staff focus more time on patient
care and less time on record keeping
 Improved communication of patient history for
better clinical treatment, especially in
emergency departments.
 can facilitate information and responsibility
sharing to improve patient decision making

25. Discuss the legal and ethical issues associated with
computer based patient record.
 Right of Privacy
 The Federal Privacy Act and provide assurance
that patient records held by the government and
governments of states that have enacted privacy
legislation will not be disclosed to third parties
without the patient's consent, except under defined
circumstances. when patient records are
computerized, they can easily be transmitted
across state lines, limiting the ability of any one
state to protect the privacy of its citizens.

26.  To the extent that patients and providers are aware that
computer-based patient records increase the threat to
patient privacy, particularly with regard to sensitive matters,
such as abortions, AIDS, psychiatric problems, and drug or
alcohol abuse. Thus, the lack of adequate, uniform, national
protection of patient privacy with respect to patient records
may hinder full development of computer-based patient
record systems.
 The Uniform Health-Care Information Act skillfully
addresses issues of confidentiality and release of patient
information. Only Montana, however, has enacted this act
into law

27.  Right of Access to Health Records
 Most states expressly allow a patient or a
patient's authorized representative to inspect
and copy the patient's hospital records. Rights
of access to health records maintained by
physicians and other individual health care
providers may not always be clear. A few
states grant patients the right to review their
hospital records only after discharge.

28.  Many states permit providers to refuse to grant
a patient's request for disclosure where
psychiatric records are involved and where
release of the information would be detrimental
to the patient's mental health or general health,
or where a third-party could be endangered by
the release.
 The Uniform Health-Care Information Act
addresses access issues, as well as issues of
confidentiality and information disclosure. only
Montana has adopted this legislation to date.

29.  Ownership of Patient Data and of the Patient
Record
 Ownership of the Patient Record
It is generally accepted that a provider owns the
physical patient records created by the provider
in delivering care to patients.
 Rights in Information Contained in the Record
Provider ownership of patient records does not
imply that the provider has a right to use,
disclose, or withhold data in the record at will.
Patients generally have a qualified property
interest in the information contained in their
medical records.

30. Review the important protection of
health care records.
 Access controls:_ to help limit access to your
information like passwords and PIN numbers,
Text/Numeric or Biometric as Face, Voice,
Fingerprint
 Encrypting your stored information. This
means your health information cannot be
read or understood except by someone who
can decrypt it

31.  Establishing sanctions for the misuse of
information
 Requiring measures for protection of health
information
 Providing consumer control over individual
information
 Setting boundaries for the use of health
information and imposing a legal duty of
confidentiality on those who provide and
receive health information.

32. References :-
 https://www.ncbi.nlm.nih.gov/books/NBK233055/
 https://www.healthit.gov/faq/what-are-differences-
between-electronic-medical-records-electronic-
health-records-and-personal
 https://www.masters-in-health-
administration.com/faq/what-are-the-similarities-and-
differences-between-an-ehr-epr-and-emr/
 https://www.bmj.com/content/322/7281/283.short

33.  https://books.google.com.eg/books?id=fwYwbJPF3rI
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2aDx5atgJ&sig=ACfU3U1NP2H_T0Fvhz1Bsgt6PW0
n2ozRlA&hl=ar&sa=X&ved=2ahUKEwjf7vLDldzhAh
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 https://www.healthit.gov/faq/what-are-advantages-
electronic-health-records
 https://www.ncbi.nlm.nih.gov/books/NBK233048/
 https://www.healthit.gov/buzz-blog/privacy-and-
security-of-ehrs/privacy-security-electronic-health-
records