This paper provides a committee-oriented overview of three foundational topics in health informatics: the structure and characteristics of database systems, the various types of medical data and electronic records relevant to a multi-facility hospital network, and the critical importance of uniform terminology, coding, and data standardization. The paper explains core database concepts such as fields, records, files, and hypertext organization, then addresses the scope of electronic medical records including sensitive personal and genetic information and related federal privacy regulations. It concludes with compliance guidelines for accurate data entry and coding, and a summary of the broader benefits of regional electronic health information networks.
This paper has been prepared for presentation to the technology review committee at our multi-facility regional hospital. The committee has been tasked with evaluating the feasibility and possible selection of a new health information system that will enable the hospital to electronically collect and share patient medical history information among its various hospital centers and departments.
Currently, each hospital center maintains paper copies and files of patient records, which are separately managed and stored at each facility. Very few of the electronically based information systems are integrated between the various centers and locations. Because most committee members have limited experience with information systems and databases, this paper provides a foundational overview of three key topics: the fundamentals of database characteristics and structure, the various types of medical data and information records relevant to this project, and the importance of uniform terminology, coding, and standardization of data.
A database — often abbreviated as DB — is a collection of information organized in such a way that a computer program can quickly select desired pieces of data. It can be thought of as an electronic filing system. Traditional databases are organized by fields, records, and files. A field is a single piece of information; a record is one complete set of fields; and a file is a collection of records. For example, a telephone book is analogous to a file: it contains a list of records, each of which consists of three fields — name, address, and telephone number.
An alternative concept in database design is known as Hypertext. In a hypertext database, any object — whether a piece of text, a picture, or a film — can be linked to any other object. Hypertext databases are particularly useful for organizing large amounts of disparate information, but they are not designed for numerical analysis.
Medical records are ordinarily scanned into the database so that they can be readily shared with others who need access to them. To access information from a database, users require a database management system (DBMS) — a collection of programs that enables users to enter, organize, and select data within a database.
Electronic medical records encompass far more than basic physical health information. They may also include data about family relationships, sexual behavior, substance abuse, and even the private thoughts and feelings documented in the course of psychotherapy. This information is often linked to a patient's Social Security number, which raises significant concerns about how it is stored and who may access it.
A particularly sensitive category of medical information is genetic data. There is widespread public concern about the privacy of this information, especially with respect to its potential misuse by insurers and employers. In response to this public anxiety, Congress attempted to develop legislation to protect individuals against adverse uses of medical information, but was unable to build a majority in support of any proposal that successfully balanced the competing interests of individual privacy against the compelling public benefits derived from using medical information to advance biomedical, behavioral, epidemiological, and health services research.
As a result, it fell to the Clinton administration to write health information privacy regulations. These regulations were announced in the closing days of that administration and subsequently implemented by the Bush administration in April 2001. Understanding the scope and sensitivity of the data contained in electronic medical records is essential context for any committee evaluating a new health information system (Silverstein, 2001).
"Compliance guidelines for accurate coding and data entry"
Some health care providers and insurance companies are forming regional information networks to share electronic medical records. Their reasoning for establishing these data repositories is to help reduce paperwork, assist with billing, identify the most cost-effective treatments, and combat false claims. With such a system in place, a patient's medical information would be immediately available to the attending physician. Therefore, if an individual were injured in another part of the country, attending physicians would have the patient's entire medical history at their fingertips — including potentially life-saving information that could prove invaluable in an emergency.
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