Communication and Customer Service in the Healthcare Office: Module 4: Maintaining Medical Records

Sending Protected Information

Although sending information by facsimile (fax) is commonly used in all types of business and personal transactions, HIPAA Privacy and Security Rules consider it to be an unsecure method of transmitting data. Therefore, it should be used as little as possible and only by health care providers for treatment purposes, such as in an emergency when faxing is the best method to send or receive necessary information; or when the patient makes a written request that a fax be sent. When a fax is sent, it should contain only the data necessary for the situation and be sent to a machine monitored by authorized health care personnel or the patient or a person designated by the patient. Include a cover sheet with a headline in bold type: Confidential Health Information Enclosed. As an additional safeguard, fax machines in health care facilities should be located in secure areas to avoid unauthorized access. When available, secure e-mails should be used to send protected health information instead of faxes. These are transmissions that are encrypted, or scrambled, as they pass from the sender's to the receiver's computer. An exception is if a patient signs a form that explains the risks to confidentiality and gives you permission to send him or her unencrypted e-mails, A number of e-mail encryption services are available, but only one that supports HIPAA guidelines should be used by the health care facility. In non-urgent cases, it is recommended that PHI be sent by U.S. mail or a messenger. Finally, there is the matter of disposing of anything that contains PHI. Paper records cannot be placed in waste baskets or dumpsters that are available to the public. They should be shredded, burned, or otherwise made unreadable. Prescription bottles with patient names should be stored in opaque plastic bags and picked up by a professional disposal vendor. Electronic records should be cleared or purged, using specialized software that makes the data inaccessible.

RAM

An internal computer workspace that stores data only while the computer is on.

It is not necessary to document patient behaviors, such as not taking prescribed medications, because this is the patient's responsibility, not the health care provider's.

False

Problem-Oriented Charting

Problem-oriented medical records are organized around the patient's health problems. After the initial assessment is completed, a list of problems and related plan of care are identified, and then all subsequent charting refers back to this problem list. If new problems develop, they are added to the list and dated. If a problem is treated and no longer exists, it is marked as resolved and dated. The advantage of this approach is that all health care professionals focus their charting on the same problems. The disadvantages of this approach are difficulties in keeping the problem list up to date and the possibility that patients may be seen more as problems to be resolved than as individual human beings.

networks

Systems of computers that are linked so they can communicate and share data.

The format for charting each problem is known as SOAP. These letters stand for the following components of the documentation:

S—Subjective: This is information that is sensed and reported by the patient. Known collectively as symptoms, they describe how the patient feels as a result of a disease or injury. It is best to record the patient's own words as closely as possible. Use quotation marks when noting exact words. The chief complaint is the reason the patient is seeking medical care and is included in the subjective section of the record. Significant patient behavior, such as missed appointments, failure to follow directions, and statements about discontent with treatments, should also be included in this section. O—Objective: This information includes the observations made, and measurements taken, by health care personnel and are known as signs. Included are temperature and blood pressure; lab test results; description of a wound; color, temperature, and moisture of skin; and how a patient walks (gait). A—Assessment: The assessment is the health care professional's impression of what is wrong with the patient, based on the signs and symptoms. P—Plan: The plan documents the procedures, treatments, and patient instructions that make up the patient care.

Computer Security

There are precautions the health care professional can take to help ensure computer security. If assigned a password to gain access to a computer system, never give it to anyone else, even a coworker. Unauthorized users may be able to destroy or falsify data, add hours to their payroll records, or illegally transfer funds. Entries can often be tracked to the password used. The following practices will increase computer security: If passwords are chosen rather than assigned, do not use something obvious, such as a nickname. Close files containing private information before leaving the work area. Do not allow patients or other unauthorized persons to wander into the area where data entry is taking place. Shred discarded printouts before throwing them in the trash. It is not always obvious that a virus is present because the instructions may have been programmed to activate at a future date. All computers are susceptible to viruses. The following practices can help prevent viruses from infecting workplace computers: Do not open email messages or download files from unknown parties. Do not use your work email address for personal correspondence. Use purchased software to load application programs, not copies secured from friends or other outside sources; or download directly from the vendor's Internet site. Use antivirus software or an online service and keep it updated to protect against new viruses that are continually being created. Wireless technology has its own security threats. When using public Internet access ("hot spots"), do not enter private passwords to websites or personal data, such as credit card numbers.

computer viruses

are programs that contain instructions to perform destructive operations, such as scrambling and erasing files and preventing the computer from operating normally. A common means of transmitting harmful programs is by clicking on links contained in emails from unknown sources or downloading "infected" material from the Internet.

To authenticate medical records, they must be

dated and signed by the health care professional.

robotics

help paralyzed patients walk

virtual reality

help patients overcome anxiety

"Two Minutes - What's the Risk? Documentation" https://www.youtube.com/watch?v=42pWreEAuDQ&t=27s The purpose of medical records has now expanded to include them as

legal documents.

portable diagnostics

make patient the point of care

Digital tattoos involve the use of

microchips

record

A collection of related computerized data.

SOAP

A format for charting that uses a problem-oriented approach.

file

A group of related computer records or documents.

electronic mail

A means of creating and sending messages from one computer to another, using the Internet system of networks. Commonly called e-mail.

plan

A step in SOAP charting that documents the procedures, treatments, and patient instructions that make up the patient's care.

Internet

A vast global system of computer networks linked with other networks that allows instant communication and the sharing of information.

Maintaining the Human Touch

Although computers have become part of everyday life, there are still people who are not familiar or completely comfortable with this new technology. They complain that they feel like a number in a vast system over which they have little control. This perception may result in feelings of intimidation and annoyance. In fact, some physicians have resisted the implementation of EHRs because they have difficulty focusing on a patient, maintaining eye contact, and observing the patient's body language, while simultaneously entering data into a computer. The health care professional should strive to provide a personal interface between patients and machines. Do not let the computer become a barrier. Those responsible for inputting patient data should extend a friendly greeting before beginning the data entry process. Look up and make eye contact periodically. If it is not obvious to the patient, explain what information you are entering and why. Make appropriate comments to convey a sense of caring to the patient. Communicate verbally and nonverbally that the patient is more important than the machine. Health care professionals should also be prepared to respond to patients' concerns about the privacy of their medical records, identity theft, and the possibility of errors being entered on computers.

When should you record a cancelled or no-show appointment?

Always

Evaluating Internet Sources

At this time, material placed on the Internet is not regulated. Anyone can say anything and make any claims; therefore, not all information is reliable. Much of it consists of personal opinions or is motivated by the desire to sell products. Health care professionals must take care to determine the reliability of any information taken from the Web. The following guidelines can help you evaluate websites: Identify the source: Universities and government agencies tend to be reliable sources of information. Research and professional organizations, if not organized for the purpose of selling specific products, may also be reliable—for example, the American Heart Association and the American Association of Medical Assistants. The ending of a website address gives information about the sponsor. (See Table 18-2.) It should be noted here that commercial websites can be good sources of information. Many large corporations provide nonbiased information. Determine the author: Is the person an expert in the field? Does he or she have appropriate education and credentials? Is the purpose of the material to share information or report research findings? Or to persuade readers and sell ideas or products? Check for accuracy: Is a reference given for the information? Is the reference from a reliable source? Verify important data: Cross-check statistics and other numerical data. Look for signs of quality: Are the ideas well supported? Is the spelling accurate and vocabulary used correctly? Check for currency: Is the information recent and up to date?

Providers' Concerns

Barrier between them and their patients. Patients see their physicians staring at a computer screen instead of interacting with them. A related concern is that inputting data is cutting into the time providers would rather spend caring for patients. Technical malfunctions or software that does not meet all the requirements of the organization. A related problem is the start-up time needed when a new computer system is introduced, especially problematic in places such as busy hospital emergency departments where there isn't time for personnel to quickly learn the new system. Over-standardization that allows input only for the fields that have been entered into the system, making it difficult or impossible to enter lesser-used medications or treatments.

fields

Basic data categories in a database.

Charting by Exception (CBE)

Charting by exception is an abbreviated format. Only abnormal findings are noted. This requires a well-defined understanding of the normal findings that are used for a comparison. If no abnormal findings are found, then no written notes are required. The advantage in this approach is that it saves time and that the problems are easily identified by reviewing the notes. The disadvantage is that it is problem oriented, so the preventative or wellness aspects of care are not included.

Characteristics of Good Medical Documentation

Complete: All requested information must be included. Each entry must include the date and signature of the appropriate health care personnel. Charting should be completed as soon as possible to prevent the omission of important information. Concise and factual: A lot of words are not better than a clear concise statement. Never use the chart to record guesses or opinions. State only what has been observed, done, or heard. If you are quoting a patient's statements, use quotation marks. For example, "I feel a sharp pain in my left leg every time I try to walk." Properly identified: The patient's name and identifying numbers should be visible on every page. It is critical that the record match the patient so that correct entries are made. Legible: Notes that cannot be read are useless. They do not serve their purpose of providing continuity of care. Furthermore, they present a liability and cause for negative legal and regulatory outcomes. Uses correct spelling, terminology, punctuation, and grammar: Poorly written documentation can be easily misinterpreted and gives the appearance of carelessness when the record is reviewed by others. Clearly and objectively expressed: Important details are correctly noted: temperature, size, amounts (fluids, drainage, medication, etc.). The words used are not subject to misinterpretation, such as "small," "a lot," and so on. Notes should be limited to what is observed. For example, write "ate 25% of the meal" rather than "ate poorly." Judgmental or humorous remarks about patients are unacceptable. Does not duplicate findings: Some facilities use graphic sheets on which the blood pressure, temperature, pulse, and respiratory rate are recorded. If so, it is not necessary to repeat this information in the written record. When a finding is abnormal, it may be repeated in the written record along with the associated action taken or treatment given to correct the problem. The record would then also include a follow-up assessment of how the patient responded to the action or treatment. Uses abbreviations only if approved and listed in the facility's policy manual: This reduces the possibility of misunderstandings if the abbreviation used has several different meanings. For example, does "pt" stand for patient, prothrombin time, physical therapy, or part-time? Shows time and date of all entries: Accurate and chronological charting presents a picture of how the patient appears over time. If charting is not done in a timely manner, another health care professional may record an event with a time that occurred after the action that you intended to chart. The only option then is to write "late entry" and then chart, but this out-of-sequence information can still create confusion for others. (See Figure 19-1.) Signed by the proper person: Never sign for someone else or have anyone sign the charting you have done. Recording false information is a serious offense and should not be done under any circumstance. Completed without leaving empty lines: All charting that begins after the previous signature and runs to the next signature belongs to the latter entry. If an empty space or line is left above the entry and signature of the health care professional, it is possible for someone else to chart information that now becomes part of the other health care professional's entry. (See Figure 19-2.) Never enter in advance of the medication or procedure: Chart only after the event has occurred, never before, in anticipation of doing it. For example, if a nurse charts that medications were given and then is suddenly called away, the other health care professionals will assume that the medications were given, and the patient will not receive the proper medications he or she needs for treatment. Written with black or blue ink (or as specified by the facility): Pencil is never acceptable.

Diagnostic Imaging Techniques

Computed tomography (CT) X-rays are taken from many angles. Measurements of the density of tissues are converted to cross-sectional views. Evaluate soft tissues for presence of disease and conditions, such as blood clots, fractures, and tumors Magnetic resonance imaging (MRI) Patient is placed in a magnetic field. The activity of hydrogen atoms in tissues is measured and converted into cross-sectional images. View tumors clearly View brain structure and abnormalities See movement in the body, such as blood flow Positron emission tomography (PET) A radioactive substance is injected into the patient and detected by a scanner, resulting in three-dimensional images. Determine how brain is functioning; used with Parkinson's and Alzheimer's diseases, epilepsy, cancer Can study effects of drugs on the brain and on some forms of mental illness Ultrasonography High-frequency sound waves hit tissues and organs and bounce back as echoes. The signals obtained are used to create images. View movement Used when X-rays might cause harm, as with a fetus Examine organs Detect tumors, aneurysms, and blood vessel abnormalities Electrical impedance tomography (EIT). Conducting electrodes are attached to the skin. Electrical currents are measured to detect differences in tissue. Proposed for: Monitoring lung function Detecting skin and breast cancer Producing images of the brain to locate hemorrhages, areas with inadequate blood supply, and sources of epileptic seizures

Computers In Health Care

Computers and their applications have influenced every aspect of modern health care. From patient check-in procedures to diagnostics and research, technology is changing the way that health care is delivered. All health care professionals now function as information managers, and the ability to use computers has become an essential part of health care competency. Computers perform three major types of operations: Store huge amounts of data Calculate, manipulate, organize, and retrieve data quickly and accurately Enable high-speed communication We can see more clearly the impact of computers on health care by following one patient, Mr. Johnson. Mr. Johnson was mowing his lawn on a Saturday afternoon when he experienced chest pains and nausea. His wife took him to the emergency department at nearby Ames General Hospital. Here are some of the many ways that computer technology was used during his stay at Ames: Mr. Johnson was seen by a physician immediately, because of the possibility that he was suffering a myocardial infarction (heart attack). Mrs. Johnson gave information about Mr. Johnson and their health insurance coverage to the admitting clerk, who entered it on the hospital's computerized patient record system. An electrocardiogram (ECG, a diagnostic method used to measure the heart's electrical activity) was performed on Mr. Johnson. The results were interpreted by a computer. Dr. Sanchez, the cardiologist on duty, examined Mr. Johnson and decided to admit him to the hospital for observation. He dictated his observations, using voice recognition software, into the medical record. A room was scheduled for Mr. Johnson using the hospital's computerized scheduling program. Orders for medications prescribed by Dr. Sanchez were sent via a computer network to the hospital pharmacy. A hospital pharmacy technician used a pharmaceutical software program to compare the new medications with those that Mr. Johnson was already taking to check for possible drug interactions. All supplies used for Mr. Johnson's hospitalization were tracked on a computerized inventory system. This information was used for reordering supplies and preparing billing statements. Mr. Johnson's blood pressure and pulse were intermittently monitored at preset intervals by computerized equipment at his bedside. Mr. Johnson is diabetic and the nursing assistant took his blood sugar level before meals and at bedtime. She used a handheld piece of equipment called a glucometer that has computer components for testing blood and storing the readings. Mr. Johnson's blood and urine samples were sent to the laboratory for computerized processing. As soon as the tests were completed, the results were entered and available on computer for the staff to review. Mr. Johnson's charge nurse entered nursing notes about his care and condition directly into the electronic health record system that his health care team could access. When Mr. Johnson was discharged, he was given instructions about diet and exercise that had originally been created with word processing software. The type and number of computer-related tasks performed by health care professionals depend on their specific occupations and factors such as the size of the facility in which they work. Duties range from simple data entry to interpreting diagnostic test results. Employees in small facilities sometimes need to have a wider variety of computer skills than those in larger facilities, which have computer specialists on staff. For example, a dental receptionist in a single-dentist office may be asked to research and purchase a computer system to upgrade the administrative functions of the office. Large facilities, such as hospitals and groups of associated clinics, have information technology departments with specialized staff who purchase and maintain the computer systems. They may also design and program customized software.

search engine

Computer software program capable of searching through and retrieving millions of documents on the Internet by using specific key words as identifiers.

Rehabilitation

Computer technology has helped people with disabilities live more independently. Commands that can be activated with the touch of a button or pad, the voice, or simply by eye contact with the monitor allow the control of household functions. These include turning lights and appliances on and off, answering the telephone, and controlling room temperature. Computer-aided design has contributed to improvements in prosthetic devices. For example, artificial legs can be designed that more exactly fit the physical characteristics of the individual. Tiny microprocessors can be inserted in prosthetics to improve their movement and to allow them to be better controlled by the user. In another application, computer technology enables the electrical stimulation of muscles that no longer receive stimulation from the brain through the nervous system. Scientists are even developing ways to enable brain function to operate prosthetic devices, thus enabling paralyzed individuals to move by using their thoughts.

Medical Lab Testing

Computers are used extensively in medical labs for both diagnosing and research.

plagiarism

Copying the work of someone else and presenting it as one's own work.

What is 3-D printing?

Creating objects in layers using computer technology.

medical history

Data collected on a patient that includes personal, familial, and social information.

electronic medical records (EMRs)

Digital versions of patient records, such as history and physical, physician's orders, and test results. (Also called electronic health records.)

electronic health records (EHRs)

Digital versions of patient records, such as history and physical, physician's orders, and test results. (Also called electronic medical records.)

personal health records (PHRs)

Documents created and maintained by an individual patient to assist him or her in communicating with various health care providers to ensure greater continuity of care.

point-of-care charting

Entering information about patients into the computer when at the patient's home or health care facility bedside.

An example of a chief complaint would be when the health care provider notes an increase in blood pressure that requires treatment.

False

Comprehensive systems for maintaining computerized patient records are fairly inexpensive to purchase and implement.

False

Faxes are a good way to efficiently send patient records to another provider.

False

lasers

Focused light rays that can cut and remove tissue.

virtual communities

Groups of individuals who use the Internet to communicate and share information with each other.

computer literate

Having the knowledge and skills to efficiently perform the computer tasks required in one's work, as well as a basic understanding of how computers work and what types of health care applications are currently available.

Advantages of Computerized Systems

In addition, the following advantages that can improve patient care make the case for the switch to computerization: Reduction of errors: This is considered to be one of the most significant advantages of computerized recordkeeping. Handwriting can be illegible and transcription miscommunicated. These common errors are less likely to occur with the computer. Safety features: Many EMRs have flags or hard stops if an order is placed incorrectly, such as the wrong dosage of a medication. Easier access: Authorized health care professionals can access the patient's medical record from a variety of locations. Improved communication: Health care professionals can more easily exchange information, especially those who work in different departments or facilities. Also, systems can enable patients to view their own records, see upcoming appointments, and send e-mails to their providers. Standardization: Standard recordkeeping formats throughout the systems further improve communication between staff and departments. Improved privacy: Electronic records, if secured with passwords and encryption, are less at risk than paper records which are usually not stored in locked areas and may pass through many hands. Improved efficiency: Test results, for example, can be uploaded quickly and used by professionals immediately to make diagnoses and recommend treatment. Information sources: Extensive libraries of information can be accessed for provider research and clarification of recommended treatment protocols. Patient information and education: Documents that detail what has been ordered, future appointments, and any screening tests that are due can be printed out for patients to take home. If the system is tied to a patient education databank, educational materials can be printed out for patients to refer to later to reinforce information that may have been missed or forgotten when explained verbally at the visit. Addition of documents: Many systems can accept scanned documents. This allows for other forms of written material presented by the patient or a family member to be included in the computerized system, if they are deemed helpful. Other helpful features a computerized system may have are "copy and paste" and "smart phrase" functions. These features have the ability, with only a few key strokes, to add extensive text to your document. Both features can save a great deal of time when charting commonly performed actions because much of the information does not have to be retyped. However, it can lead to problems if not used with caution. Information that is copied and pasted from a previous entry should be modified to demonstrate updated content with relevance for the current date. Although inserting a smart phrase that details the entire procedure you may be preparing to perform can be very advantageous, blanks frequently need to be filled and findings relevant to the process added to personalize the entry. Leaving the information unaltered, without modification, can misrepresent the patient's condition or the care provided during the encounter.

Learning More about Computers

Learning more about the capabilities and operation of computers can increase the efficiency and job satisfaction of the health care professional. Opportunities for promotion may be increased. The many ways to increase computer knowledge and skills include the following: Take classes Read the manuals (often online) for software Work through tutorials and help menus included with software programs Take tutorials available on the Internet Explore the various functions of software programs Read some of the many books that are available for all levels of users Research topics on the Web

medical documentation

Notes and documents that health care professionals add to a patient's medical record.

site licenses

Permission granting the installation of software on more than one computer.

A variation of the SOAP charting is SOAPIE. The S, O, and A have the same meanings as just described. The P and the additional letters stand for the following:

P—Plan: What is planned for tests and treatment? I—Interventions: What interventions are actually carried out? E—Evaluation: Evaluation of the interventions. What were the results? Was the treatment effective?

charting

Recording observations and information about patients.

Cybersecurity

Social security numbers, personal IDs, and sensitive health facts have been reported stolen by hackers who demand huge payments for the return of the data. The individual health care professional can help prevent these thefts by taking the following steps: Be aware of the importance of protecting patient data Practice good computer habits, such as closing programs when not in use Back up files Use strong passwords and change them regularly, following your facility's policies (A strong password consists of at least six characters, the more the better, that are a combination of letters, both uppercase and lowercase, along with numbers and symbols [@, #, $, %, etc.] if allowed.) Never share your password with anyone Secure your laptop to prevent it from being stolen

electronic spreadsheet

Software that permits the user to apply the computer's ability to perform high-speed calculations of numerical data.

artificial intelligence

Sophisticated technology that enables machines and/or computers to make decisions traditionally believed to require human intelligence.

cloud storage

Storage of digital data on multiple servers and sometimes at multiple locations.

fiber optics

Technology that uses hair-thin cables to transmit data.

medical record

The collection of all documents that are filed together and form a complete chronological health history of a particular patient.

Contents of the Medical Record

The medical record will be organized according to facility policy, and the health care professional is expected to maintain the integrity of the record by following all policies and procedures. Many physician offices will have a continuous chronological record format, but in large health care facilities there may be a source-oriented approach. This approach divides the record into different sections separated by tabs for each health care specialty. This has the advantage of making it easy to find specific information related to a specialty, but has the disadvantage of increasing the difficulty of seeing the overall view of the patient because many sections need to be referred to for the complete picture. In a source-oriented charting format, the chart may be separated into the following sections: History and physicals (H&P) and consultations: Typed or handwritten reports on the initial findings of all physicians seeing the patient. The primary physician will do a complete medical history, which includes a personal, familial, and social history. The personal history includes the patient's past medical problems and surgeries, allergies, current problems, assessment of each body system (see Chapter 20), and medications. The familial history lists medical problems of relatives that may indicate a tendency for the patient to develop these problems. The social history includes use of tobacco, alcohol, and illegal drugs. The suspected diagnosis and plan for further assessment and treatments are also included in the medical history. Consultations occur when the primary physician asks another physician to see the patient for further evaluation of a specific problem. Some facilities have transcription services in which the physician dictates the detailed findings and then the transcriptionist types from the taped message. This is then placed in the chart for the physician to review and sign. Physician's orders: Written record of all orders for medications and treatments prescribed for the patient. Diagnostic tests: Any report that includes findings obtained in an attempt to diagnose or monitor the progress of patients, such as the results of laboratory tests, X-rays, and electrocardiograms (ECGs). Admissions: Completed forms and consents that deal with the admission process. Surgical procedures: Consents for, and reports related to, any surgical procedures performed. Graphics: A graphed format for blood pressure, temperature, pulse, and respiratory rate; may also have spaces for height and weight. Flow sheets: Forms for specialty needs, such as monitoring blood sugar levels or measurements of a wound as it heals. Many specialty fields create forms specific to their needs. Medication record: Includes all medications administered by health care professionals at the facility. Photos: Some facilities allow the use of photos that document physical conditions related to dermatology, plastic surgery, orthopedics, etc. An example of their use is to document progress as treatment progresses. Progress notes: Written chronological statements about a patient's care. For example, each time a physician sees a patient he or she will make an additional note to update findings and plan for the care of the patient. Therapists (e.g., physical, occupational, and speech therapists) and other services (e.g., social workers, chaplain services) will note what was done and their assessment of results. Nurses will record what treatments they perform, the patient's response, any abnormal assessments, and plans for intervention. In large facilities, the physician, therapists, and nurses may have different sections of the chart in which to record their documentation. When filing forms, reviewing charts, or charting, always verify that the correct form is in the chart by checking that the patient's name is on each document. An incorrectly filed form can lead to misunderstandings and errors. When filing or adding additional blank forms to the chart, always place them in the correct section in chronological order. The forms within each section will be chronological. The most current is usually on top, depending on facility policy. If using paper charts, and the file becomes too thick, another file on the patient is started. This is referred to as "thinning a chart." A note is then made in the new chart that an older file exists for this patient. When requesting charts, always make sure that you have all the charts on the patient for review.

bioinformatics

The organization of biological data into databases.

database

The organization of computerized information in a structured way that makes it easy to sort and access.

chief complaint

The patient's statement of the main reason he or she is seeking medical care.

telemedicine

The practice of medicine, such as diagnosing and recommending treatment, via electronic communication.

An important result of the widespread use of computers is the elimination of repetitious tasks.

True

Medical records are legal documents that can be used as evidence in court.

True

progress notes

Written chronological statements about a patient's care.

Using Computers Effectively

You can increase the effectiveness of computers as work tools by using the following good work habits: Verify the accuracy of all data entered: When working on a large system, incorrect entries can negatively affect the work of others as well as the welfare of patients. Many medication errors in hospitals are the result of incorrect data entry. Health care work demands accuracy to ensure high-quality patient care, as well as compliance with regulatory agencies. Always back up work using a backup system, such as an external hard drive or cloud storage service (services run on the Internet): Save work to the hard drive periodically. The workspace on a personal computer, called RAM, stores data only while the computer is on. If power is interrupted, any work not saved will be lost. Many software programs save work automatically at regular intervals. When a task or work session is completed, back up all files if not using an automatic storage system. Computers can break down, and emergencies can occur. Stay legal: It is against copyright law to install software that has been installed on another computer unless it is specifically allowed and stated by the manufacturer. Purchase and register needed programs. Site licenses that give permission to install software on more than one computer can be purchased for programs that will be loaded on more than one computer at a facility. Never bring personal software to load onto the workplace computer. (Some of these problems have been solved by software companies that now require you to purchase their programs directly online.) Keep up with advancements: Software is continually updated with new versions that offer additional features. Many updates are available at reduced prices for owners of previous editions. New websites, offering an increasing number of products and services, appear daily. Do not panic: Computers are still a relatively new technology, and the complexity of today's systems results in occasional glitches. It is almost impossible to damage computer hardware or software through normal use. If the computer does not understand a command, an error message will appear on the screen. These error messages can sound rather serious, but the worst thing that can usually happen is that work performed since it was last saved—either by the user or automatically by the program—is lost and must be redone. As discussed earlier, this can be avoided by regularly saving work. This said, entire system crashes do occur and thus there is the need to back up your files. Be flexible: When large facilities update or change their computer system, the transition can be stressful. During the first few days after "going live," it can seem as if the new system adds more work instead of more efficiency. It can take staff members time to learn and adapt to the changes. Fortunately, software analysis, design, and support are continually improving and making information technology easier for everyone to learn and use. Avoid injury: Prolonged use and improper positioning can result in physical injuries. See Chapter 9 for information about reducing the risk of workplace injuries, such as carpal tunnel syndrome, related to computer use.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

an organization that accredits those health care organizations that meet its standards.

Opinions of a health care professional about the nature of the patient's problem

assessment

Recording observations and information about patients

charting

Reason the patient seeks medical care

chief complaint

chabots

communicate easily with health care providers

Measure density of tissues to perform evaluations

computerized tomography

3-D printing

create customized splints and casts

tissue engineering

create organ tissues

Measure electrical currents to detect differences in tissues

electrical impedance tomography

The physician's orders are the primary tool used to record, communicate, and coordinate the care given to the patient.

false

nutrigenomics

individualized diet recommendations

Measure hydrogen atom activity to view tumors

magnetic resonance imaging

All notes added to a patient's medical record

medical documentation

Collection of documents that forms the complete health history of a patient

medical record

Use injected radioactive substance to study brain function

positron emission tomography

The use of the Electronic Communication Privacy Act of 1986 _____ against the unauthorized access to computerized records.

protects

artificial intelligence

recommend best treatment options

Measure signals from sound waves to examine organs and fetuses

ultrasonograpgy

Which sponsor is most likely to have a website that contains current and accurate information about the link between nutrition and cancer?

university medical school

digital tattoos

use microchips to take vital signs

Informed consent must be carefully documented.

True

It is predicted that in the future, robots will be able to work on their own.

True

The emerging medical advances discussed in the video are based on computer technology.

True

augmented reality

enable surgeons to enhanced view of patient

Information Management

A database is a collection of information organized in a structured way. A small medical office might use a software program to develop a database of all active patients served by a specific insurance company. Many vendors today sell medical record and practice management software designed for small offices. Some have been created for particular specialties, such as pediatrics. Complex database management systems for large facilities have been created by a number of companies. Examples of Health Care Database Disease profiles Insurance company records Inventory management Mailing lists Patient records Personnel records Pharmaceutical records Production reports Research projects and results The basic structure of a database is the key to its usefulness. Each collection of related data is called a record. For example, the data about each individual are grouped together in a separate record. These data are entered into fields. Suppose that a computerized patient record contains 15 pieces of demographic information, such as name, address, telephone number, occupation, and insurance company name. A collection of related records is a file. Computerized databases have many advantages over paper filing systems. The following features make them especially useful in health care information management: Records can be retrieved quickly and easily. Records can be sorted, accessed, and reported in many ways. For example, patient records can be organized alphabetically by last name, grouped by zip code, grouped by insurance company, or listed chronologically by date of last visit. Information can be accessed by more than one person at the same time. Additions and changes can be entered easily. Reports can be generated as needed. Quality improvement studies can be conducted. Accuracy is critical when entering data. Patient diagnoses, treatment plans, and billing are negatively affected by incorrect data. Carefully review and verify all input.

Creation of Documents

Computers are excellent tools to help create high-quality written material. Word processing software converts the computer into a "super typewriter" that gives the user the capability to create customized documents that are error-free. Written materials of all types—letters, reports, forms, and newsletters—can be produced with word processing software. Software programs are available that enable the user to perform the following functions: Design the appearance of text and documents Edit, correct errors, and check spelling and grammar Store documents for later use Print and send documents by email, fax, or direct connection to other computers Using Word Processing in Health Care Announcements Business letters Home care instructions Information sheets for patient education Medical reports Memos Newsletters Payment collection notices Research reports Desktop publishing software is related to word processing software. It enables the user to easily combine text and graphics to create attractive newsletters, brochures, calendars, announcements, and so on. Presentation software carries documents a step further. Users can create slides to project from a computer, usually a laptop, onto a screen. Digital slides are commonly used for making professional presentations and for teaching. Voice dictation software, a form of voice recognition software, converts spoken words to text. Increasing numbers of health care providers are using this technology for patient charting, reports, and standardized forms. Information that is dictated appears on a screen and the speaker can edit it as needed. Another type of software allows the speaker to complete the dictation and then sends the text to a professional medical transcriptionist for final editing. Voice dictation software has improved in accuracy over the past several years and has several advantages over traditional transcription services, which rely on handwritten documents from health care providers: It eliminates the problem of illegible or difficult-to-read handwriting. Reports tend to be more complete, as individuals can speak faster than they can write. The turn-around time for a complete, printed report is much faster. It is nearly as accurate, with one study showing it to be within 1.2 percentage points. The cost is considerably less.

Education

Computers offer new ways to learn for students, health care professionals, and patients. Distance education over the Internet is widely available. This is a method of accessing courses enabling students to study at times and locations convenient for them and to proceed at their own pace. As discussed in Chapter 14, this is a way for health care professionals to earn continuing education units, as well as to keep up on the latest developments in their career fields. The Internet allows storage of vast amounts of reference information. Entire sets of encyclopedias, reference books, and specialized dictionaries are available online. Wireless devices can hold thousands of pages, offering a convenient, mobile method for downloading and reading books in electronic form. A.D.A.M. is an example of how the power of the computer can be harnessed to help students learn. Designed to teach anatomy, it is an interactive resource that contains a multimedia encyclopedia, more than 3,000 illustrations, and three-dimensional images that can be rotated (A.D.A.M. Education, 2017). A.D.A.M. is also available for consumer (patient) education. Computerized simulations provide scenarios that allow students to interact. A realistic situation is presented, followed by questions and opportunities for students to suggest appropriate action. The computer responds to the student's input, either indicating its correctness or requesting more information. Virtual reality technology, in which reality is simulated as closely as possible, enables health care providers to practice procedures before working on patients. These include inserting needles and performing surgical tasks. Surgeons can practice entire operations before working on actual patients. Many professional licensing exams are now administered by computer. In the past, exams may have been offered only once or twice a year and graduates had to wait until they were scheduled. Some testing programs now individualize the exams by selecting each question based on the response given for the previous question. Test-takers who answer all or most questions correctly may pass the exam with fewer total questions. An example of this type of test is the National Council Licensure Exam (NCLEX), which is administered to registered nurse candidates. Patients, too, can learn about their health conditions, self-care, and prevention techniques using the Internet. Credible, user-friendly websites, such as Medline Plus, offer dozens of articles, slide shows, and illustrations to inform health care consumers. Some hospitals make it possible for patients to obtain computerized health information.

Example of a Computerized System

EMRs and EHRs can go far beyond the core charting to include multipart systems that coordinate with laboratory, radiology, pharmacy, admission-discharge-transfer functions, and tools to allow data exchange. For example, for Ellen Nordstrom's visit with Dr. Stevens, the following transactions can take place: Ellen makes an appointment to see Doctor Stevens and the receptionist records the time and date. Before the appointment, Dr. Stevens quickly reviews Ellen's record to see the past history, current medications, and recent labs. Ellen arrives at the front desk, the receptionist records her arrival time in the computer, and the back office personnel are notified. The medical assistant takes Ellen to the exam room, takes her vital signs, and enters them into her electronic medical record. During the visit, Dr. Stevens records his findings. Following the visit, Dr. Stevens can electronically order any new medications, labs, or other tests and place referrals. After the visit, Ellen can go to the lab, pharmacy, radiology, or other area where the orders will already be in the computer.

Identifying Website Sponsors

Educational institution .edu University of Michigan, www.umich.edu Government office or agency .gov National Institutes of Health, www.nih.gov Professional organizations .org American Cancer Society, www.cancer.org Businesses, corporations, and other commercial organizations .com Merck & Co., Inc. (pharmaceuticals) www.merck.com

Electronic Health Recordkeeping

Electronic health records (EHRs)Electronic health records (EHRs)Digital versions of patient records, such as history and physical, physician's orders, and test results. (Also called electronic medical records.) When the decision to computerize charting is made, facilities have three options: Purchase a computerized program package and use without modification Purchase a computerized program package and pay for modifications to the system to meet the facility's specific needs Develop a computerized program package for their own individual needs The choice of options is greatly influenced by identifying the needs of the facility versus the cost involved in the purchase and implementation of the program. These options are listed from least to most expensive. The most common decision by a facility is to choose option number 2. Most computerized programs are not specific enough for the individual needs of the facility, but trying to design a customized version is both very costly and time-consuming. In addition, many facilities do not have the in-house expertise to design such a sophisticated program. The software vendor and facility enter into a contract that details the cost of any modifications. The need to modify is likely to decrease in the future, as vendors are learning to create systems that more closely meet the needs of specific types of facilities, such as hospitals.

Electronic Mail

Electronic mail (email) has become a standard professional communication tool. It provides a way to quickly send documents, such as memos, announcements, and reports to one or more persons. Some physicians and other health care providers are using email as an efficient means of communicating with patients. It is important that email messages be clear and accurate, just as with any written material. The growing popularity of email means that some people receive dozens of transmissions daily. Keeping messages brief and to the point is considered a professional courtesy. Additional guidelines for professional health care emails include the following: State the email's purpose or content in the subject line Maintain a professional tone: avoid humor, sarcasm, and anything that might be misinterpreted Include a greeting and a close that includes your contact information Do not use all caps (shouting) or all lower case (hard to read) Do not use abbreviations or emojis, such as those used in casual text messages Do not include confidential patient information (HIPAA rules are very strict - see Chapter 19) Proofread before sending, checking grammar, punctuation, and spelling When sending to more than one person, use BCC Keep in mind that emails, like other written documents, reflect the professionalism of your organization. In spite of the convenience of emails, there are times when a phone conversation is more appropriate. This may be true when the message is complex, difficult to explain, and might require a number of emails to complete; when an immediate response is needed; or when the topic is difficult or emotional, such as when a patient's test result is abnormal and a matter of concern. Files created in other programs can be sent with an email message. For example, a report created in MS Word can be sent as an "attachment" to an email message without rekeying the document. This provides a convenient and economical way to send, review, revise, and return documents and share useful information. Suppose that two respiratory therapists in different states are working together to write a journal article. Using email attachments, they can send updated drafts of their work to each other for review. However, patient records and other documents containing personal health information should never be attached to an email. A more recent development for sharing documents on the Internet is Google Docs which allow multiple users to edit a document with each able to immediately see the changes made by others. It is not appropriate to conduct personal email correspondence or explorations on the Internet at work. Be aware that email messages may be stored in the form of backup files that belong to the employer. Employers have the right to read and monitor any messages sent through their computers by any employee. Many organizations have increased their monitoring of employee activity on the Internet.

Spreadsheets

Electronic spreadsheet software enables the user to perform high-speed calculations of numerical data. Spreadsheet software consists of intersecting rows and columns that form squares called cells. The user enters numbers and formulas (instructions for performing calculations) into the cells. To create a simple budget using spreadsheet software, the amounts of income and expenses and the formulas for the desired calculations are entered. A formula may have several steps. The budgeting example would allow the user to calculate monthly income by adding all income and subtracting all expenses. Electronic spreadsheets provide the basis for billing and accounting programs. In addition to speed and accuracy, these programs allow changes to be reflected throughout the spreadsheet. For example, if the cost of a clinic's rent increases, the effect on income can easily be calculated. All numbers affected by the change in rent will automatically be adjusted. Computers have significantly changed patient billing methods. Amounts to be billed are not only calculated electronically, but they are also sent electronically to payers instead of being mailed. The computer matches the codes for various procedures to a fee schedule and prepares bills. Additional numerical codes that identify specific insurance companies can be entered so that bills are automatically prepared in the proper format. The high speed of computer calculations also enables the user to employ "if . . . then" scenarios to explore a variety of options. Questions such as the following can be posed: "If the number of patients visiting the clinic continues to grow at the current rate, how many full-time medical assistants will be needed next December?" "If we finance the purchase of new medical equipment at 6.5% interest, how much will the total cost be if the repayment period is three years? Five years?" Electronic spreadsheet programs can also be used to create graphs and charts that illustrate numerical concepts and statistics. As with databases, it is critical that data entered into the spreadsheet be accurate. One incorrect entry can affect hundreds of numbers. Carefully check all electronic spreadsheet entries.

Purposes of Medical Documentation

Good medical documentation and recordkeeping contribute to quality health care in the following ways: Improves the coordination and continuity of care. Reinforces decision-making capacities: Information contained in records provides health care providers with the information they need to make decisions about proper diagnoses, treatment options, etc. Helps enforce staff accountability: When information is "officially" noted in a record, the health care professionals making the notes can be held responsible for its content and any actions on their part. Achieves more accurate vital statistics: Information about deaths, disease outbreaks, etc., can be extracted from medical records rather than from oral reports that may be erroneous. Provides legal protection: Medical records are legal documents that are admissible as evidence in court. In the case of a malpractice lawsuit, for example, documentation provides proof of what has taken place with the patient. Only through written documentation can tests, procedures, and treatment be proven to have occurred. In the world of health care, "If it isn't documented, it isn't done." Helps ensure compliance with regulatory agencies: These include governmental bodies and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) an organization that accredits those health care organizations that meet its standards. Participation in certain programs, such as Medicare, requires that specific documentation guidelines be strictly followed. Improves cost control: Proper documentation prevents repetition and the performance of unnecessary procedures. It also helps ensure that appropriate preventive measures, early intervention, and correct procedures are performed. Decreases denials from insurance companies: The need for care and proof that it is provided by appropriate personnel are supported by documentation. Provides data for investigation of errors and incidents: Errors do sometimes occur during surgeries, the administration of drugs, etc. Accurate records can assist in the investigation, analysis, and prevention of future errors. By contrast, poor records can have the following negative consequences: Misinformed health care professionals and patients Increased legal risks Unnecessary repetition of tests and other investigations Longer hospital stays Poor patient care Risk of repetition of serious incidents

HIPAA (Health Insurance Portability and Accountability Act of 1996)

Government law mandating significant changes in the legal and regulatory environment governing the provision of health benefits, the delivery and payment of health care services, and the privacy and security of individually identifiable, protected health information in written, electronic, and oral formats.

Research

Learning and keeping up-to-date with medical advances has been made easier by computerized resources. The National Library of Medicine, through MEDLINE/PubMed, contains millions of citations to journals and books. Literature databases are like giant indexes, containing references to specific journal articles, books, and research reports. Each entry is accessible in various ways, such as the following: Preassigned key words that describe the content Words in the title Name of author(s) Name of journal Publication date Other specialized databases are available in addition to MEDLINE. One of potential interest to health care students is the Cumulative Index to Nursing and Allied Health Literature (CINAHL). It contains indexes for more than 4,000 journals, including full-text availability for 1,300 journals. Two other large, specialized indexes of interest to health care students are the Educational Resources Information Center (ERIC) and PsychINFO. In addition to providing published information, databases can serve medical researchers by their capacity to sort and match data. The term bioinformatics refers to the organization of biological data into databases applying information technology and computer science. Such databases make information easily available to scientists all over the world. Sharing information in this way contributes significantly to scientific progress. The Human Genome Project is an example of bioinformatics. Begun in the late 1980s and completed in 2003, it was an international effort to collect the results of investigations relating to human genes (one of the biological units of heredity). The goal of the project was to identify all the approximately 20,000 to 25,000 genes in human DNA and store this information in an organized manner. Gene therapy is an exciting area of medical research that uses the results of the project. In this therapy, a "normal" gene is inserted into a cell to replace an "abnormal," disease-causing gene. Pharmaceutical research has benefited from the computer's ability to sort and match the results of thousands of tests carried out to explore the effectiveness and safety of new drugs. Results can be obtained more rapidly and sent to the Food and Drug Administration for review. This is decreasing the time needed to obtain approvals for new products.

Treatment

Many new methods of treatment are based on sophisticated technology. Fiber optics is a technology that involves the use of hair-thin cables to transmit data. Their use for both viewing and working inside the body has increased the safety of surgery. A tiny camera, inserted through a narrow tube, projects images along the cable onto a screen, allowing the physician to see the inside of the body without having to make a large incision. When surgery is required, tiny instruments are introduced through other tubes and the procedure is guided by images on the screen. These micro-tools reduce healing time as well as the chance of infection. Robotic surgery is made possible by fiber optics. An advanced method of surgery, it benefits patients by increasing accuracy and using minimally invasive procedures. As with expert systems, robots are not intended to replace humans. In fact, surgeons must receive special training and guide every movement made by the robot. The success of this type of surgery depends on the expertise of the "human partner." Sophisticated cameras provide surgeons with high-resolution, three-dimensional images. Sophisticated robots can be matched to the surgeon's voice and follow oral commands. This enables surgeons to perform procedures at a distance as they watch a monitor and guide the movements of the robot. Robotic surgery is currently used in many types of surgery, including cardiac, gynecological cancers, head and neck cancers, and urological procedures. Another treatment technology involves the use of lasers, focused light rays that can cut and remove tissue. Lasers are guided by computerized measurements to make precise incisions. A common use is for corrective eye surgery. Laser procedures are also used to remove diseased tissue and to treat bleeding blood vessels. Image-guided surgery is based on a nearly three-dimensional mapping system that combines computed tomography (CT) with real-time information about the exact position of surgical instruments using infrared signals. This makes surgery more accurate and is especially useful when previous surgeries have changed the usual formation of a patient's body part, such as can happen with nasal surgery. As with robotic surgery, image-guided surgery tends to be less invasive and more accurate. Clinical decision-support systems (CDSS) in use today include: GIDEON (Global Infectious Diseases and Epidemiology Network): Support for diagnosis and treatment of infectious diseases TherapyEdge-HIV: Decision support system for treating human immunodeficiency virus (HIV) Artificial intelligence, although intended to make computers behave like humans, is intended to assist health care professionals, not take the place of trained individuals. The reliability of expert systems varies, and they are not meant to be substituted for human input and decision-making.

Medical Documentation and Recordkeeping

Medical documentation consists of notes and documents that health care professionals add to the medical record. Examples of data contained in these records include patient statistics and information about care, results of tests performed, the patient's diagnosis written by a physician, treatments received, and medications prescribed. A medical record is the collection of all documents that are filed together and form a complete chronological health history of a particular patient. A medical record is also commonly referred to as a medical chart, patient chart, or patient record. Recording observations and information about patients is known as charting. Many health care professionals are responsible for some aspect of charting. Tasks may include the following: Recording demographic information about new patients Interviewing patients and filling in the medical history form Recording vital signs (e.g., temperature, blood pressure) Noting comments made by the patient Making notes on the patient's record as dictated by the physician, dentist, or other professional Recording any procedures performed Transcribing notes or dictation from other professionals into the medical records

Making Corrections on Medical Documentation

Medical records cannot be corrected in a way that covers up what was originally written. To do so can give the appearance that the records have been illegally altered and negates their value as legal records. Never use correction fluid (such as White-Out), erase, or use correction tape over errors. Observe the following practices: Draw a single line through the error. The original entry must still be legible. Write in the correct information where there is the most space: above, below, or following the original entry. Note the error as required by your facility. For example, "M.E." may be used for "mistaken entry"; "correction" or "corr" may be acceptable. Be sure to learn the specific requirements for notations, and never create your own or assume that the facility will use the ones presented in textbooks. Regulatory agencies differ in the terms accepted, and it is important to carefully follow their guidelines. Date and initial the correction. If an error is made while typing or word processing a document, you may correct it as you work. If an error is made when entering data electronically, it cannot be deleted. Instead, there will be a special field in which to note the error.

Pharmaceuticals

More than 50% of Americans take prescription medicine regularly. It is significant, then, that computers have improved many aspects of the dispensing of pharmaceutical products. Drugs, including anesthetics, are accurately measured and dispensed through computer-controlled devices. The chance for error is decreased, as well as the potential for abuse by health care professionals. Adverse drug incidents, estimated at one million annually, harm or cause the death of thousands of patients each year. These incidences include dosage errors, patient allergies, and dangerous drug interactions. One technology that shows promise to prevent these errors is the computerized physician order entry (CPOE) system. In this system, the prescribing provider enters medication orders into a computer that contains patient information, standard dosages, drug interactions, and so on. The system uses these data to check the appropriateness of an order before sending it to the pharmacy. The FDA Adverse Event Reporting System (FAERS) is a database that contains information on adverse event and medication error reports submitted to the Food and Drug Administration. A system for tracking such errors has been developed and is involved in pilot testing in several states. Telepharmacies allow the dispensing of drugs at sites other than pharmacies. Instructions for prescriptions are sent to a computerized dispensing unit. The unit prepares and releases the exact dosage. Safety features are built into the system to prevent incorrect types and amounts of drugs from being dispensed. This technology is especially useful in medical facilities that are located far from commercial pharmacies. In some rural areas, telepharmacy technology provides services to customers from a pharmacist physically located at a central pharmacy site. Using video conferencing technology, the pharmacist communicates with the customer and a certified pharmacy technician who prepares the drug for dispensing. The pharmacist performs a drug utilization review, prescription verification, and patient counseling just as he or she would do if present in person. Several states have passed legislation that enable telepharmacies to serve outlying populations.

Narrative Charting

Narrative charting includes detailed written notes on all aspects of care. It includes routine care, normal and abnormal findings, and any other information related to the patient's plan of care. The advantage of this approach is that the health care professional can use his or her own approach to describe the patient and the care given. The disadvantage is that it is often time-consuming and results in an extensive written record that is difficult to read through to find specific information.

Communication

Networks, computer systems linked together to share date, enable communication among the staff of one clinic or among a group of thousands of individuals the world over. An example of a simple networked system is five linked computers in a small medical office. Patient records are shared, and all staff members use the same printer. A large facility may have hundreds of computers linked together that carry out many of the functions described in this chapter. The Internet is the ultimate networked system, consisting of billions of computers located all over the world. Known as patient portals, they can be used by patients to access appointment dates, test results, reminders about vaccinations that are due, and much more. Securing this information is critical and records can only be accessed using an individual's login and password.

Personal Health Record

Personal health records (PHRs) are documents created and maintained by individual patients to help them communicate with various health care providers. Due to the mobility of individuals and the frequent changes in health care providers and insurance groups, it is recommended that each individual keep a PHR to ensure greater continuity of care. When patients bring their own PHR with them it benefits both the provider and the patient. It helps prevent the patient from forgetting information and also minimizes long delays on the provider's end in requesting the information from a prior source. The type of information frequently provided in a PHR includes the following: Demographics, such as name, address, and contact information Emergency contacts Name, specialty, and contact information of previous health care providers Insurance provider(s) Medical directives, living will, organ donation, and so on General medical information: height, weight, blood type, vital signs, and so forth Allergies and drug sensitivities Current conditions and dates of diagnoses Previous surgeries, including date and results Medications (prescription and nonprescription) Immunizations and when last received Any relevant health care visits, such as hospitalizations, other specialists or therapists Pregnancies Medical devices Foreign travel Family history information

Patient Monitoring

Physiological monitoring systems employ computer technology to oversee critical body functions, such as heart and respiratory rates. Alarm systems may be connected to various types of monitoring systems to advise health care personnel when patients need intervention. Computer systems also enable health care professionals to enter and track data for charting and recordkeeping. Bedside terminals and mobile computers enable keyboard entry of information, such as vital signs, dispensing of medications, fluid intake and output, and other information about care. This is known as point-of-care charting. Physicians who cannot get to the hospital can review patient data, look at X-rays and test results, and recommend treatments from anywhere in the world. Computerized devices are also used by home health professionals, such as nurses and physical therapists, to record patient notes and progress. This information is then transmitted electronically into the patient's health record. Making sure that data are entered accurately when working in the field is extremely important. Many specialized devices have been developed to assist health care professionals in tracking patient recovery. For example, a camera connected to a computer allows hand therapists to store and compare photographs of the patient's hand taken over time. This aids in evaluating the effectiveness of the treatment plan.

HIPAA

Recall that HIPAA mandated significant changes in the legal and regulatory environment governing the provision of health benefits, the delivery of, and payment for, health care services, and the privacy and security of individually identifiable, protected health information (PHI) in written, electronic, and oral formats. It is the Privacy and Security Rules that are of greatest significance to medical records. The Privacy Rule gives the patient specific rights related to his or her medical record, such as the right to request: Access to and copies of the medical record An amendment to the medical record An accounting of disclosures of PHI A limit on information about himself or herself that is provided in a hospital directory The Security Rule has administrative, physical, and technical safeguards. The following examples pertain to electronic PHI: Administrative safeguards: Developing security policies and procedures regarding use of electronic health records (EHRs); training the entire workforce on implementation of these policies and procedures Physical safeguards: Preventing unauthorized viewing of computer terminals by positioning them in appropriate locations, having screes that cannot be read from side angles, and not propping open doors that allow unauthorized access to private work areas Technical safeguards: Following good password policies and logging off the computer when stepping away If you are working with paper charts, it is important not to leave them lying around where others can view them. Specific rules and regulations dictate who can be given copies of a chart and what procedure must be followed to request copies. Ask your supervisor for these guidelines and follow them without exception. If you are working with computerized records, your computer must be locked before leaving the station to prevent others from casually viewing the record. Many computers are located in traffic areas and a privacy screen placed over the monitor prevents others from reading the material unless they are directly in front of the monitor. Remember that patients' medical information belongs to them and them alone. No one else has a right to that information, regardless of the relationship, without the consent of the patient. If a patient is unable to handle his or her own health care decisions, then a power of attorney should be on file specifying who has the authority to receive information and make decisions. This limitation of access also applies to health care professionals. If you are not actively involved in a patient's care, you do not have a right to access that patient's chart. You also do not have a right to access a coworker's chart or a family member's or friend's chart. Breaking any of the HIPAA regulations could result in a lawsuit by the patient and/or corrective action that could include the following: Notification of the federal government if an incident involves a Medicare patient. Notification of the individual patient whose PHI was illegally accessed, used, or disclosed. Corrective action, up to and including termination, for the individual health care professional responsible for the incident.

Social and Professional Networking

Social networking websites, such as Facebook, have become a popular way for individuals to connect with friends and share personal news. By providing the means to easily stay in touch with family, friends, and former classmates, you can use social media network in your initial job search or when looking to change jobs throughout your career. A word of caution: Posting unflattering images of yourself, intended to be funny or entertaining, may be a harmful career move. This is because employers are increasingly checking social networking sites when considering applicants for employment. Showing yourself in a situation that demonstrates poor judgment, lack of respect for others, or other unfavorable characteristics could prevent you from being hired. In extreme circumstances, it can be cause for dismissal from a job. In addition to Facebook, there are many networking sites that link people around the world who share common interests. One large specialty website is LinkedIn, which promotes professional networking. Members' profile pages emphasize their employment history and education rather than personal information. The company reports that many of its members are employment recruiters who use the site to look for and check on potential job candidates.

Challenges of Computerized Systems

Some of the major benefits of computerization can also present problems, as seen in the following list of potential challenges: Cost: Purchasing a system can cost a small physician clinic hundreds of thousands of dollars; a system for a hospital or multifacility organization can cost millions of dollars. Including the initial cost, staff must be trained and the system must be maintained. For many individuals and organizations, these costs can be prohibitive. Cybersecurity: Some experts believe this to be the most serious threat to the computerization of health care information management. This is one reason for the passage of the Health Insurance Portability and Accountability Act of 1996, discussed later in this chapter. It is reported that in 2015, 113 million health records were compromised, 78.8 million of them in a single cyberattack. In response, cybersecurity budgets have increased, although it is reported that fewer than one third of U.S. health care organizations have a comprehensive cybersecurity program in place (https://www.hipaajournal.com/category/healthcare-cybersecurity/). According to Becker's Hospital Review, data breaches cost the health care industry $5.6 billion every year (https://healthinformatics.uic.edu/resources/articles/cybersecurity-how-can-it-be-improved-in-health-care/). Incompatibility of Systems: Many EMRs and EHRs have been developed by a variety of software companies. In the hurry to create systems for sale, many companies used variations of existing software. Adding to incompatibility of different systems is the competition between developers who do not want to share their data. As a result, it frequently happens that health care facilities cannot communicate with each other, leading to communication breakdowns, repetition of procedures, etc. This also leads to inconvenience for patients. For example, a patient may have an internist, a cardiologist, an ophthalmologist, and one or more other specialists involved in her care, with each using a different software system. This patient must set up a personal ID and password for each different computer system so she can access her health data or e-mail her provider. Some standards have been proposed to make systems more able to communicate seamlessly, but all parties must agree on what these are and this takes time. Some have proposed that it will take the collective effort of the government, providers, payers (Medicare and insurance companies), and patients to lead to true compatibility (also called interoperability) of EMRs and EHRs.

Remote Diagnostics

Technology enables information to be transmitted to nearly every corner of the earth, enabling health care providers to diagnose patients who cannot be examined by a health professional face-to-face. In addition, treatment advice and follow-up can be provided remotely. While this was developed to help patients in remote locations, clinics and hospitals now are using remote connections to diagnose and monitor patients in their homes. Examples of what is currently available include the following: Web-connected stethoscope that transmits heart and lung sounds Device that transmits data while a patient is sleeping at home to diagnose sleep apnea (disorder in which breathing stops and starts) Blood pressure cuffs that transmit information to a health care provider so medication can be adjusted if needed Blood glucose Sleep patterns

Telemedicine

The American Telemedicine Association defines telemedicine as "the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status." Transmission devices may include two-way video, smart phone, email, and various wireless tools. The medicine practiced by telemedicine is the same as that practiced in face-to-face consultations. Its major advantage is that it provides expert medical help to patients in remote areas, such as farms far from towns, war zones, and wilderness areas. It is also increasingly used where convenience, rather than distance, is the issue. As discussed previously, patients can be monitored while remaining in their homes. A physician can send patient information to a colleague halfway around the world to obtain an opinion about a rare condition. Because images can be transmitted electronically, X-rays and other images can be sent for analysis. One hospital emergency department in Oregon sends CT scans of patients admitted during the night to Australia to be interpreted if there are no radiologists on duty at the hospital. Telemedicine is especially helpful for the following functions: Allowing patient access to specialists who are located at a distance Communicating vital signs from home to allow monitoring at a health care facility Checking pacemaker function and performing ECGs over telephone lines Performing physical exams from a distance Providing more comprehensive emergency care by linking emergency medical professionals in the field and during patient transport with physicians Although telemedicine has become an important part of health care delivery, there are three major obstacles to its expanded use: Not all facilities, especially those in remote areas, have adequate infrastructure to support the necessary high-speed wireless technology. State licensing laws sometimes prohibit the exchange of medical practice across state lines, even when done electronically. Some physicians are not comfortable conducting examinations remotely. Complex government regulations make it difficult or impossible for community based, non-profit, or public agencies that serve low-income patients to bill for telemedicine services.

The Internet

The Internet began as a method for government authorities to communicate in case of nuclear attack. It has rapidly grown to become a principal means of communicating, conducting business, shopping, learning, securing needed information, and socializing. Using the Internet for Research: Health care professionals can benefit from the Internet in many ways. Consider the case of Mark, a recently graduated nurse, who is hired by an orthopedic surgeon who specializes in joint replacements. Mark wants to learn more about these procedures and decides to see what he can find on the Internet. In one afternoon, he locates the following resources: Articles in medical journals Information produced by, and about, companies that manufacture artificial joints A newsgroup in which patients who have had joint replacement surgery share their experiences Articles in popular magazines, such as Newsweek A list of medical facilities and surgeons in the United States who specialize in joint replacement Government reports about the effectiveness of artificial joints Email addresses of university researchers who are experimenting with new types of artificial joints A medical bookstore that takes orders over the Internet Mark started by using a search engine, a program on the Internet that looks through millions of documents. In his case, he entered the key phrases "joint replacement" and "artificial joint." Google and Bing are examples of general search engines. There are more targeted search engines, such as Google Scholar, PubMed, and Science Direct, that limit searches to non-commercial websites. The major search engines allow you to be more specific by specifying phrases that must appear exactly as you enter them. In Mark's case, if he enters the words artificial joint, a search engine will find documents that contain both these words—but not necessarily together. (Search engines are becoming much better at recognizing these types of common phrases.) Using the advanced search function, or by enclosing the phrase in quotation marks, Mark increased his chances of finding useful websites. It is important for students to remember that they must cite (give the source of) information taken from a website and used in a report or paper just as they would for material taken from a book or journal article. Copying information word for word from a Web source or using materials such as images without permission is plagiarism. There are several ways to correctly cite and list Web sources, just as there are different ways to organize a bibliography or reference list. Check with the appropriate style manual or your instructor to learn the preferred form.

Diagnostics: Diagnostic Imaging

The computer's ability to mathematically convert thousands of measurements into images has encouraged the growth of technology that permits the viewing of soft tissues not possible with traditional X-rays. Safer and more efficient ways of seeing the inner workings of the body continue to be developed and implemented in modern medical facilities. Dentistry has been improved by the introduction of safer methods of X-ray. Digital X-rays can now be taken, in which a small electronic chip is placed in the patient's mouth and an image sent to a computer. Viewed on the monitor, it can be enlarged, studied, and then stored in the patient's electronic record. The patient is exposed to a smaller amount of radiation than with traditional X-rays.

Progress Notes

The progress notes make up the written record of every aspect of a patient's relationship with the health care providers. They are the primary tool used to record, communicate, and coordinate the care given to the patient. Careful documentation is a critical skill for the health care professional. Before charting, it is important for the health care professional to take a moment to organize his or her thoughts. For example, health care professionals can ask themselves what they observed while working with a patient, what has been done for the patient, and what the patient's response was to any interventions. It is important to always address the primary problem that required the assistance of health care services. There are several ways to organize progress notes. It is the responsibility of health care professionals to learn the formats used at the facilities in which they work.

Virtual Communities

Virtual communities consist of individuals who use the Internet to communicate and share information. Both health care professionals and patients can share information and experiences about specific health conditions. Chronically ill, bedridden, and people with disabilities use the communication capabilities of the computer to break from the isolation that often results from these conditions.