Electronic Health Records

Over the past five decades healthcare record keeping has been evolving. In order to protect patient 's records and encourage healthcare providers to keep up with current technology trends several federal agencies have been developed. As a result of these agency formations several laws and regulations have been put into place. The development of healthcare information technology (HIT), and subsequently the rules and regulations, began to evolve in the 1960 's with the development of Medicare and Medicaid under President Johnson. At this time a major reason for the development and evolution of health records and later, electronic health records, is healthcare reimbursement. Proper documentation and data tracking needed to take place to insure
proper reimbursement. As we are seeing now with "Meaningful Use", the development and evolution of HIT deals with money and reimbursement. Over the last five decades health care records have evolved from paper and pencil to electronic health records (EHR). There were multiple problems associated with paper based records which led to the development of EHR in hoped to eradicate these errors. Some of these problems, that EHR resolves are: illegible writing, incomplete, inaccurate notes, the record being in only one place, records taking up a lot of space and difficulty of collecting and aggregating information across patients, providers and organizations (Buchbinder and Shanks). The development of computers over the 1970 's and into the 1980 's took electronic medical records to a whole new level, making computers more affordable and computer programs more available. Healthcare IT took off in the 1980 's with the development of local area networks and subsequently in the 1990 's with the world wide web. These developments in technology led to more resources and accessibility to physicians and healthcare providers by such means as "physician portals" in which the patient can view their records and has better communication with their healthcare provider means such as email (Wagner, Lee and Glaser). With the development and evolution of EHR, and thus furthering the technology, laws needed to be put into effect in order to protect patient 's data and minimize data tracking errors. Carlos Leyva describes Health Care IT Law on his website, www.lawtechtv.com, as "health informatics law deals with evolving and sometimes complex legal principles as they apply to information technology in health-related fields. It addresses the privacy, ethical and operational issues that invariably arise when electronic tools, information and media are used in health care delivery. Health Informatics Law also applies to all matters that involve information technology, health care and the interaction of information. It deals with the circumstances under which data and records are shared with other fields or areas that support and enhance patient care." In 1991 the Institute of Medicine brought international attention to problems with paper based records and called for the adoption of computer based records.
The computer based records were defined as "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, links to medical knowledge and other aids (IOM, 1991, p. 11). Five years after the IOM 's paper the Health Insurance Portability and Accountability Act (HIPAA) was signed into law. HIPAA was designed to lessen the costs of insurance, as well as make it more accessible, it also included provisions to protect the confidentiality of patient 's records (Wagner, Lee and Glaser). In order to protect patient 's records HIPAA requires healthcare entities to: install safeguards to protect personal information, limit access to who can view personal information and limit usages and access to records to the minimum to accomplish the treatment (HIPAA). Prior to HIPAA there were no federal regulations on health care privacy and patient -specific information. This lack of restriction enabled employers to view medical records of their employees; this led to several employees being terminated for health conditions such as seeking treatment for drug or alcohol addiction (Wagner, Lee and Glaser). In today 's healthcare setting if these privacy rules are broken an agency can be fined. The
amount of the fine is based on the type of violation committed and it is up to the discretion of the Secretary of the Department of Health and Human Services to determine the amount of the fine. The minimum a fine can be is $100 while the maximum can be as high as $1.5 million (HIPAA Violations and Enforcement). In order to avoid fines the healthcare practice must follow the guidelines set forth in the HIPAA, this means proper documentation and furthermore, proper privacy of that documentation. Today, if we look at EHR from a behavioral psychology standpoint, there 's positive and negative reinforcement. This means there are certain goals that can be met in order to receive incentive money (as with meaningful use) and there are fines if certain laws are broken (such as HIPAA violations). In 2009 the American Recovery and Reinvestment Act (ARRA) allocated $19 billion in order to assist physicians and hospitals achieve "meaningful use" of health information technology (About ARA). In order to receive the incentive money, providers have to show they 're "meaningful using" their health information systems. A timeline was set in place with several phases and goals to reach. One of the goals (phase 1) that must be met is implementing certified electronic health records technology. Once stage 1 was met the hospital, or healthcare provider, has 2 years to reach stage 2. Stage 2 requires demonstrating the meaningful usage of the acquired technology. There are numerous goals to be met during this phase, the primary indicator in phase 2 is reporting clinical quality measures during each year of operation (Meaningful Use). Subsequently there are three stages for technology usage: stage 1- technology adoption, stage 2-technology implementation, stage 3-meaningful use of technology. The goal of the ARRA, and incentive money, is to improve technology which will improve diagnosis, lower costs (by reducing repetitive tests) and improve efficiency and effectiveness. Initiating the incentive money will help even the playing field between high capital and low capital healthcare providers (Srinivasan). The maximum amount of incentive money for a Medicare EHR program is $44,000 and the maximum amount for a Medicaid EHR program is $63,750 (Centers for Medicare and Medicaid Services). Another similar incentive program offered by the Centers for Medicare and Medicaid Services (CMS) is the medical ePrescription Incentive Program, which offers incentives to practices who prescribe Medicare patients medication electronically. This program began in 2009 and incentives that year were as high as 2% of a provider’s total estimated allowed charges for covered services for one calendar year. 2013 was the last year to receive an incentive and the amount had dropped to 0.5% of estimated allowed charges; 2014 was the last year to be fined. Providers who were unsuccessful with this program were subjected to a 2.0% payment adjustment on their Medicare Part B services provided (Centers for Medicare and Medicaid Services, 2014a). In order to receive the incentive money and avoid penalties, the health care practice most properly file the prescription and document the medication in the patient 's file. Although several laws and regulations have been passed at the federal level, patients reportedly are "largely unaware" of their privacy rights.
The 2007 report, The Health Privacy Project indicated many patients do not trust their providers and that one in five American adults believes that their information may have been improperly used. In order for patients to truly understand these rules and regulations proper education needs to take place. The patient needs to trust their healthcare provider and understand that their information is truly protected by
law. A governing agency that is affiliated with hospital accreditation is the Joint Commission. The Joint Commission has developed several guidelines in order to insure patient safety, these are referred to as the National Patient Safety Goals (NPSG). Each year the Joint Commission releases a set of safety goals that must be reached for accreditation , the most recent set of goals went into effect January 1, 2014. Some of the goals that are listed for patient safety are:
Goal 1 - Improve the accuracy of patient identification
NPSG.01.01.01
Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment
Label containers used for blood and other specimens in the presence of the patients.

NPSG.01.03.01
Make sure that the correct patient gets the correct blood when they get a blood transfusion
(The Joint Commission, 2014) In addition the NPSG the Joint Commission also looks at information management. The Joint Commission states "information management function is to support decision making to improve patient outcomes, improve health care documentation, assure patient safety, and improve performance in patient care, treatment and services, governance, management and support process (The Joint Commission, 2004)."
Examples of Management of Information Standards:
IM 2.10
Information privacy and confidentiality are maintained
IM 2.20
Information security, including data integrity, is maintained
(The Joint Commission, 2008)

Both the NSPG and Management of Information Standards are important when taking information and tracking data for healthcare providers. Each are equally important in their own way and both are mutually important in that one relates to the other. In order for patients to receive the right treatment or medication, the information and data integrity must be managed and maintained. This is also important if providers wish to receive an incentive and avoid a penalty, such as with a HIPAA violation or with the eprescription program. The CMS gives several tips on their website in order to avoid penalty fees. Some of these tips are: retaining documentation, communication with the vendor to insure proper documentation and G-codes, and review the remittance advice (Centers for Medicare and Medicaid Services, 2014a). The goal of EHR and Healthcare Information Technology (HIT) is to increase efficiency and effectiveness of healthcare while keeping costs down(Srinivasan). In order for this to take place proper data tracking and record keeping needs to take place. In order in insure this is happening federal agencies have developed rules and guidelines to either incentivize programs or penalize providers. For the healthcare provider to receive such incentive such as with the meaningful use program proper documentation of records and software needs to take place. In order for providers to avoid penalties from HIPAA violations or eprescription programs, again proper documentation and record keeping needs to happen.

References:

About ARRA. (2014). ARRA Economic Stimulus Package. Retrieved June 27, 2014: http://www.hitechanswers.net/about/about-arra

Buchbinder, S.H and Shanks, N.H. Introductions to Health Care Management. Sudbury, MA: Jones and Bartlett Publishers. 2007.

Centers for Medicare and Medicaid Services. (2014). EHR Incentive Programs. The Official Web Site for the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs. Retrieved June 27, 2014: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/

Centers for Medicare and Medicaid Services. (2014a). Electronic Prescribing (eRx) Incentive Program. Retrieved June 27, 2014: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html?redirect=/erxincentive/

Health Privacy Project (2007). Health Privacy Stories. Retrieved June 27, 2014: http://www.healthprivacy.org/usr_doc/privacystories.pdf.

HIPPA (2014) How is my health information or medical record protected by HIPAA?. Retrieved June, 27 2014: http://www.healthit.gov/patients-families/faqs/how-my-health-information-or-medical-record-protected-hipaa

HIPAA Violations and Enforcement. (2014) American Medical Association. Retrieved June, 27 2014: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/hipaa-violations-enforcement.page?

Institute of Medicine. (1991). The computer-based patient record: An essential technology for health care. Washington, DC: National Academies Press.

The Joint Commission on Accreditation of Health Care Organizations. (2004). JCAHO Hospital accreditation manual 2004. Oakbrook Terrace, IL: Author.

The Joint Commission. (2014). 2014 National Patient Safety Goals. Retrieved June 27, 2014: http://www.jointcommission.org/standards_information/npsgs.aspx

The Joint Commission (2008). JCAHO Hospital accreditation manual 2008. Oakbrook Terrace, IL: Author.

Leyva, C. (1/3/10) HITECH / HIPAA: What is informatics law? Retrieved June 26, 2014: http://www.lawtechtv.com/home/2010/01/according-to-a-recently-released-book-edited-by-renown-healthcare-informatics-guru-renato-me-sabbatini-phd-handbook-of-bi.html

References Continued:

Meaningful Use (2014). 2014 Definition Stage 1 of Meaningful Use. Retrieved June 26, 2014: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html

Srinivasan, D. Impact of Healthcare Informatics on Quality of Patient Care and Health Services.Boca Raton: CRC Press. 2013.

Wager, K., Lee, F., Glaser, J. Healthcare Information Systems. (2nd ed.) San Francisco: Jossey-Bass. 2009.