Health Insurance Portability and Accountability Act (HIPAA) and protected health information are applicable to electronic health records (EHR). The patient has a right to privacy in regard to all their health care information (U.S. Department of Health & Human Services Office for Civil Rights, n.d.). This information must only be shared with authorized personnel who provide direct care to the patient. EHRs use data encryption and security measures to protect this data. The user has a password to access the system. If patient portals are in use, the patient can access using PINs or passwords. All information contained in an EHR is to be used for the purposes of patient care or data aggregation to improve patient outcomes (U.S. Department of Health & Human Services Office for Civil Rights, n.d.). It is the legal obligation of a facility or provider to notify patients of any data breaches and the Secretary of Health and Human Services.
EHR documentation as an advanced practice nurse can be time-consuming. This can impact the partnership between nursing and patient. The patient must be able to develop a rapport with the nurse in order for cooperation and collaboration towards the patient achieving healthful outcomes(McBride et al., 2018). The advanced practice nurse who follows a clinical decision support system because it is required when contraindicated in a specific patient population creates a legal situation where they cause harm to the patient. An example is a patient with a history of heart failure who presents to the emergency room with a diagnosis of possible sepsis through a CDSS symptom recognition pattern. The patient in fact had an exacerbation of CHF based on history and further assessment (McBride et al., 2018). The EHR will continue to identify sepsis and gear orders towards sepsis management. Following these order sets would be detrimental to the patient’s health. It is important for nurse educators to understand and teach these concepts to students.
HIPAA violations result in fines or time in prison or both. I would maintain patient privacy by not speaking in public areas about PHI. This means creating a private area to speak to patients and families without others having the ability to overhear. The EHR must be locked when I am not in attendance. Family members must provide the PIN or code necessary to get any information in person or via phone. The patient must clearly state who he/she wants to have his/her information shared with unless there is a legal document giving an individual power of attorney for health care.
Referenes
McBride, S., Tietze, M., Robichaux, C., Stokes, L., & Weber, E. (2018). Identifying and addressing ethical issues with use of electronic health records. Online Journal of Issue in Nursing, 23(1). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-23-2018/No1-Jan-2018/Identifying-and-Addressing-Ethical-Issues-EHR.html#McBride7
U.S. Department of Health & Human Services Office for Civil Rights. (n.d.).
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