The Use of Electronic Health Record Data for Clinical Research - Essay Example

Reflective Summary As more things become more advanced and modern every day, it is no surprise that even medical data of patients have become accessible through the utilization of the electronic health record. Data of patients including medications, laboratory reports, allergies, and problem file, to mention a few, are easily made available to improve the quality of patient care in a healthcare setting. It certainly makes searching for and entering data about a patient more convenient, makes relay of information to and fro health care providers easier, and makes communication flow more freely. Of course, the electronic health record system is not perfect. There are still several aspects that need improvement such as standardization and completeness of data. Further improvements need to be done to ensure accuracy and completeness of data as well as standard use of terms in all hospitals. Electronic health records may be also used for clinical research, given the wide database of different patients with similar, if not the same, medical cases. This data would prove to be useful in determining effectiveness of treatment and would provide different views on medical approaches. However, this task is not as simple as it may seem. Getting data from electronic health records is a complex and intricate task because one would need clear and concise data for it to be used effectively in clinical research. There are too many discrepancies in data and differences in terms and abbreviations used in transcribed notes that make collection of data more difficult. After reading the article, I realized that electronic health records are useful in ways more than one. I never really thought about EHR as a vital tool in clinical research. I know that it is important for records’ sake and that it would provide all necessary information to improve the quality and stability of patient care. Its use in clinical research is very interesting. It would not only aid health care providers in identifying specific patterns in diseases, but it would also help in comparing different treatments which could show researchers the more effective ones. The use of electronic health records could also further methods of assessing quality of care given to patients. The possibilities are endless and the benefits are seemingly overwhelming. The use of EHR’s, however, can also result in violation of privacy. Privacy is an important aspect of quality health care. The problem with transcribed data from health care providers in that it includes the name of the patient, which makes identifying him or her a lot easier. For most patients, privacy is of paramount importance, especially in cases of severe or rare or stigmatized medical conditions. For me, personally, if I had a medical condition such as AIDS or syphilis, I wouldn’t want other people to know about it because it is too much of a delicate issue. Medical and clinical research is very important in the advancement of the quality of care given to patients. I agree that the use of electronic health records is a necessity but still presently insufficient to deliver quality care. There are still too much limitations and discrepancies in the system available today to answer effectively the needs of the patients in terms of quality health care delivery. I feel that there is still a lot of room for improving the EHR systems available and in use today but it would be a tedious task with the diversity present in health care systems of different hospitals in different locations. This diversity present in different health care communities becomes an obstacle in achieving an acceptable standard of the use of electronic health records. The existence of different systems of EHR can also be attributed to this diversity as a single system for electronic health records cannot comply with the requirements and expectations of all health care providers in different settings. I feel that a single EHR system would not only be more convenient, but also more effective in providing data for clinical research. It would make identifying patterns and treatment modalities less of a hassle if an accepted standard of data entry and transcription is utilized. This would also result in a higher quality of patient care, since there would be fewer discrepancies in data, contributing to better relay of information to health care providers involved in the care of the patient. I doubt, however, that this would happen in the near future because as mentioned before, the diversity among those in health care is present and their expectations and preferences are sure to differ. The use of electronic health records have been explored since the 1980s. Since then, numerous improvements have been added to make the system work better and more efficient. The clinical information presented in the electronic health records has certainly helped the health care system. It coordinates the activities of health care providers, ensures all actions carried out in relation to patient care are recorded, and makes review of information easily available and accessible that is simple to operate and understand. Through the use of paperless documentation, it saves not only time but also resources, while at the same time, providing the same ease and simplicity in using paper as a documentation medium. In the health care setting, electronic records are used for several purposes. These records hold basic information about the patients and the care provided to them. It is also used in research and quality standard monitoring. Electronic health records serve as the doctor’s mine of information about the patient on which he bases his decisions on the course and type of treatment that is suitable for the patients. It assists him in planning and making appropriate, wise, and sound assessment and evaluation of the patient. Second, electronic health records ensure adequate recording of vital patient data which is easily retrievable which in turn, would guide the doctors in determining the best treatment and course of action to take. These records would give the clinical picture of the patient without the doctor having to leaf through countless papers to find a specific piece of data. This is especially useful in emergency or acute situations when the doctor needs to make a snap decision and he needs quick access to the patient’s records. Third, electronic health records enable health care providers involved in the care of a patient to collaborate effectively with each other, through the availability of information on the different treatments and medications given to the patient. It serves as a guide for others involved in the care to base their decisions and next actions on the data in the record. It fosters teamwork and coordination of health care team members and contributes in making sure that continuous care is given to the patient. Fourth, since electronic health records include a documentation of the laboratory results and other procedures done on the patient, it would be easier to compare results of recent tests from previous ones. Discrepancies and changes would be detected faster and be more noticeable. Constant updating of the record would also ensure timely intervention to abnormal test results. Electronic health records also contribute to effectiveness of medications of patients by providing the health care team with online access to prescription writing as well as allergies and different interactions of drugs. This would ensure that medications given to the patient is safe and would not react with other medications that the patient may be taking or existing conditions that the patient may have. In the long run, this in fact contributes to safe medication administration and prevention of medication errors. Electronic health records also contribute to the maintenance of the quality of care by making all the steps necessary to ensure safety to the patient. Lastly, electronic health records provide an orderly and organized way of entering patient data in a computer. This systematic documentation would ensure that the data entered into the computer will be easily understood by other health care providers. It also makes data entry more convenient and accessible. It would also improve understanding between health care team members if the data entered in the records are logically arranged. Documentation plays an important role in patient care. A lot of mistakes have been, in the past, attributable to miscommunication and misunderstandings between members of the health care team. Medication errors have occurred before due to illegible handwriting of the physician resulting in fatal overdoses. When dealing with lives of patients, there is no room for mistake. Electronic health records have certainly helped change the documentation system of patient care. It has significantly revolutionized data entry and accessibility and the convenience and reliability it offers is hard to question. When used for clinical research, electronic health records present obstacles that may or may not be difficult to overcome. As based on the article, there are several recommendations mentioned namely linkages of health care data files, standardization of data entry methods, and prevention of using patient identifiers within the transcribed notes. Linkages of health care data files may be the hardest obstacle to cross as there are objections against it as part of people’s stand for medical privacy. Although linking health care data offers better results in terms of clinical research, privacy is still the biggest issue as some people do not wish information about their health divulged, even for research and medical studies. Standardization of data entry method would also be difficult, because of the diversity that exists. However, I believe that compromise is always an option. I believe that an individual system that can cater to the basic preferences and requirements of different health care providers is possible; after all, the patient is always the first priority and whatever works best for the patient should be prioritized by the members of the health care team. Standardization of terms, on the other hand, is easier to achieve. There needs to be an accepted standard for proper terminologies to use and stricter policies to ensure that it is followed. When it comes to the transcribed notes of the health care providers, preventing the use of patient identifiers would benefit the patient because it would ensure better protection in case of unauthorized access to the records, as privacy and security are major issues involved in the use of EHR. There are certainly numerous benefits and advantages of using electronic medical records, may it be for documenting care or for clinical research. However, there are also setbacks in its use. Privacy is a paramount concern in the use of electronic health records. Some patients may not be amenable to the accessibility of their records yet they still need to allow leeway for health providers concerned directly in their care to access these files. It would be essential, therefore, to ensure proper protection is given to the health records in terms of firewalls, passwords, and other security methods to prevent illegal and unauthorized access to health care records that may be detrimental to the patient. EHR is merely a tool in aiding health care providers improve the quality of care given to the patients. If not used and utilized properly, it might as well be useless and a waste of money and resources. I believe that it is important that proper education of health care members that would access and make use of the electronic health records be carried out to ensure that its use is fully maximized so as to save time and resources. As beneficial and advantageous the electronic health records may seem, it is still prone to human error as it is still manipulated by humans. Utilization of EHRs by hospitals and clinical researchers may prove indispensable some day if used properly and correctly and if the weaknesses of the system can be resolved and addressed promptly.   Read More