What are some of the precautions to follow when using electronic health records?

Nine examples of EHR best practices

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April 02, 2012 - An Electronic Health Record (EHR) system can be a time-saver, and even a lifesaver (in that it helps avoid mistakes in patient records). But no system is completely without potential problems.

With vigilance, good training, and common-sense precautions, your EHR system can be your practice’s strongest backbone (outside of your excellent providers and staff, of course!). Here are nine ways to ensure your EHR lives up to its best potential for your practice and your patients.

Your IT department will be involved in some of these tasks, while others would be up to the providers and their staff.

Verify that your facility performs data backups at least once daily. Talk with your IT team and make sure they have the capacity (staff, system resources) to back up the data. Ask them how often they will do full backups as opposed to incremental backups. (Full backups contain all the data; incremental backups contain only the changes since the last full backup.)

Consider enlisting a third-party data storage service to perform the data backups and store the information offsite. Your patients’ data must be safe even if a fire or natural disaster hits your facility. Make sure they have a good reputation and system for securing the data against hackers and corruption.

Verify that your facility runs continuous anti-virus and anti-malware tools. Again, make sure your IT team has first-class tools the capacity to use them. Ask them whether they have ever encountered unauthorized access to the system and what they did about it.

Set all computers to lock after a short time of inactivity, requiring a password to reactivate. This includes laptops. This is one easy way to help safeguard the protected health information (PHI) on your system.

Install alarms on laptops, and protect them against theft in whatever ways possible. Of course, this not only protects your facility’s assets, but prevents PHI from falling into the wrong hands.

Don’t leave laptops unattended. Despite the precaution above, thieves can sometimes thwart security devices. If a doctor or nurse visiting with a patient needs to leave the room momentarily, s/he should take the laptop or call another staff member into the room before leaving.

Open only one patient record at a time to avoid putting information into the wrong patient’s record. Some EHR systems don’t allow multiple records open at once except in certain situations, but if your system allows you to open more than one record, make sure the entire staff knows not to do this. This policy is very important to preserve accuracy and prevent mistakes.

Use consistent terminology when entering notes to avoid confusion and to make searching easier.

Make consistent choices when selecting from an EHR system’s list of diagnoses or other items. Some items might be very similar; suppose both “hypertension” and “high blood pressure” were available as choices. Of course, an EHR system should not offer such synonymous choices, but it can happen.

To streamline your EHR system and add clarity to patient records, consider convening a meeting of your key providers and deciding on terminology and the EHR template selections mentioned above. Then have your IT department or EHR system vendor implement your choices (except for note entries, which will be up to providers to self-police). Incorporate your decisions into the training for any new providers. Periodic reminders to your staff would also benefit your practice.

Finally, make sure your facility’s network and your EHR system have excellent security features to protect privacy. See this article for more information.

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EHR Usability
Protected Health Information

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What 3 security safeguards are used to protect the electronic health record?

The three pillars to securing protected health information outlined by HIPAA are administrative safeguards, physical safeguards, and technical safeguards [4]. These three pillars are also known as the three security safeguard themes for healthcare.

What are the four ethical considerations of the electronic medical record?

The physician and the organization is the owner of the physical medical record. [8] There are four major ethical priorities for EHRS: Privacy and confidentiality, security breaches, system implementation, and data inaccuracies.