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COMPUTERIZED MEDICAL RECORDS AND CONFIDENTIALITY

By

Michele Sielicki

A THESIS

Sublitted to
Michigan State University
in partial fulfillment of the require-eats
for the degree of

MASTER OF ARTS

Depart-eat of Teleconnunication

1986

““39

ABSTRACT
COMPUTERIZED MEDICAL RECORDS AND CONFIDENTIALITY

By

Michele Siemicki

The universal impact of health records on the population;
the presently occurring reconsideration of goals and
organization of American health care; the increasing uses of
computers in health care; and the right of individuals to

control the uses of their personal health data result in

.increasing demands for the collection, analysis and storage

of data related to medical record-keeping. Intensive need and
demand for more kinds and more detailed patient care
information are necessary for hospital completion of daily
transactions involving patient care and delivery of its
services. The computer has risen to meet these increasing

information demands, complicating the issue of

confidentiality-the central citizen right under examination
in this study. I

Telephone survey questionnaires were administered to the
medical records departments of 14 midwestern Michigan
hospitals. Under examination was the computerized system at
each facility assessing the priorities and concerns of
management and employee given a computerized medical record
and documenting whether confidentiality would arise as a
concern without interviewer prompting.

Concerns with the technology.were prevalent, with
networking/interfacing the existing system to remote
locations throughout the hospital as the most frequently
cited priority. Although 85% of the hospitals agreed
confidentiality was integral to medical record department
function, only 2 hospitals cited it as a priority. The study
concludes traditional policies appear inadequate to meet the
new flows and uses of this information and immediate concerns

with the technology displace citizen rights.

ACKNOWLEDGMENTS

My deepest thanks and gratitude go to Linda Kohl for her
unwavering assistance and support. I would also like to
express my thanks and gratitude to Carrie Heeter, for being
a mentor and friend, and for serving on my committee when
it was needed the most; to Dr. Howard Brody for his
direction and time; and to Marilyn Fife for her genuine
concern in seeing the completion of this study.

ii

TABLE OF CONTENTS

Acknowledgments
List of Tables
List of Appendices

Chapter 1: Computers, Records and Patient Rights

Introduction

How Computers Affect This Issue
Enter the Medical Record

Users and Uses

Privacy and Medical Records
Confidentiality versus Privacy

Research Questions
Methodology

Chapter 2: Utility of Computerized Systems

Results
Nature of Existing System
Access and Security
Release of Information
Management/Employee Concerns & Priorities
Existing System: Priorities/Concerns
Fully-Automated System: Priorities/Concerns

Discussion
Conclusins

Chapter 3: Private and Public Policy Alternatives

Concept Application to Automated

Medical Record Systems
1 The Need to Teach Respect for Citizen Rights
2 The Need to Apply Appropriate Security Measures
3 The Need to Insure Accuracy

iii

Page

ii

vi

10
12

15

19
22

31

31
31
34
38
39
39
43

47
56

-61

62
64
66
67

Page

4 The Need for Outside Examination 68
5 The Need to Secure Information for Public Use 69
6 The Need for Patient Representation 71
Policy Action 72
Future Studies 73
Concluding Comments 79
Appendices 83
Bibliography 236

iv

TABLE
TABLE
TABLE

TABLE

TABLE

TABLE

TABLE

fiwN

LIST OF TABLES

Hospital Size
Computer Usage
Computerized Record Systems

Management and Employee Priorities with
Existing System

Management and Employee Priorities with
Fully-Automated System

Citizen Right Priority and Computer
Knowledge

Confidentiality Priority

Page
22
32

36

40

41

45
46

APPENDIX 1:

APPENDIX 2:

APPENDIX 3A:
APPENDIX 3B:

APPENDIX 30:

APPENDIX 4:

APPENDIX 5:

APPENDIX 6:

LIST OF APPENDICES

Users and Uses of the Medical
Record

Institutional Policies for the
Disclosure of Medical Record
Information

H.R. Bill 668

H.R. Bill 2979

S. Bill 503

American Medical Association:
Confidentiality and Computers

Questionnaire

Hospital Profiles

vi

Page

83

84
91
92

110

128
131
138

Chapter 1: Computers, Records and Patient Rights

”Computers linked together through high-speed
telecommunication networks are destined to

become the principal medium for making, storing

and using records about people." 1
INTRODUCTION

Technology offers a wider range of information and
communication resources than people have ever known before.
So pervasive and influential are these resources that the
United States is said to be moving, if not already in, a
new era-- the Information Age.2 The increasing emphasis on
production, storage and distribution of information is a
major characteristic of this movement. As a result, the
Information Age assists in the evolution of a more complex
information and communications environment, resulting in a
shift of the economy from goods-production to information-
based services. Hence, industries and organizations, both
private and public, will be ”..the primary users of the new
high-technology network (with) their dependence on
the services of the new technology."3 National health
delivery systems are no exception with their support
increasingly coming from automated, computer-based data

systems with functions ranging from storage of medical

records to long-distance monitoring of patients.

2
Information then becomes "..something more transitory than
knowledge and (having) value to somebody. 4

To this end, information is regarded as a commodity.
Hence, information technologies refer to ways of gathering,
storing, manipulating or retrieving this commodity.
Computers and telecommunication links, under examination in
this study, are one of several means facilitating this
process.

This process, however, transcends the hardware,
encompassing several, complex social issues, the least not
being privacy and confidentiality. "It is important to be
aware that the computer may have some consequences for
American society that we would prefer not to have thrust
upon us..not the least of these is the danger that some
record-keeping applications of computers will appear, in
retrospect, to have been over-simplified solutions to
complex problems."5

Because of this potential danger, health care was
chosen as the basis of an examination of computers vis-a-
vis citizen rights.

Reasons for choosing this area are fourfold:

-the universal impact of health records on the population

-the presently occurring reconsideration of goals and
organization in American health care

-the increasing use of computers in health care

3

-the right of individuals to control the uses of their
personal health data.

These changes, concurrent with the growth of an
infermation-oriented society, result in increasing demands
for financing and quality assurance and the collection,
analysis and storage of data related to medical record-
keeping. "Over the past fifty years medical record-keeping
has evolved to keep pace with the changes and growth of the
health care system and many significant advances have
resulted from the adaptation of modern computer technology
to the health field."6 Intensive need and demand
for more kinds and more detailed patient and patient care
information are necessary for hospital completion of daily
transactions involving patient care and delivery of
services. Never before have hospital medical records been
subjected to so many demands for their use and disclosure
of contents.

Where ethical standards concerning the release and use
of patient care information have traditionally been the
cornerstone of the medical record, computerization of
medical records and the integration of medical and
financial data stand to jeopardize this safeguard.7 The
computer has risen to meet the increasing information
demands thus complicating the whole issue of

confidentiality, the central citizen right under

examination in this study.

4
HOW COMPUTERS AFFECT THIS ISSUE

If the hospital is the geographic locus of health care
services, the record is the information locus of medical
care. In an age of specialization, the record becomes
central to organization. Recent advances in computer
technology have allowed the accumulation, analysis and
storage of an unlimited quantity of medical records and
medical record information thus compounding controversy
over patient privacy and confidentiality.

This controversey encompasses that information
collected and documented on manual or computer files.
Privacy concerns include issues as to what information
should be recorded and how long this information should be
maintained on file. Confidentiality concerns involve
improper or disputed leakages of information that were
disclosed 'in confidence’ on the part of the patient to the
physician. Of particular relevance today is disclosure of
information about one’s sexual activity and its possible
linkage to AIDS, and drug usage. Outside knowledge of this
information (i.e.: beyond the patient and physician)
carries not only a negative social stigma but could prove a
liability in one’s obtainment of employment and insurance
coverage. The list of private and/or confidential
information that could be potentially detrimental to an
individual if wrongfully disclosed or disseminated is

endless, from abortions to extra-marital affairs.

5

Abuses are not limited to outside sources. In-house
abuses also occur when hospital staff employees, including
physicians, access information about patients that is not
needed to perform their particular job function. Another
abuse is the method employed to gain information, that
although it is public knowledge information, it is not
obtained via the proper channels by this individual.
Consequently, the protections and safeguards that exist for
the patient’s privacy are by-passed. Thus, the privacy and
confidentiality is as old and timeless as the nature of
man’s problems.

Clearly, information privacy is a concern even without
computerization. With computerization, several features
exist to enchance and complicate this issue.

One aspect is that computers move information from a
guarded medical environment into a technical one. Patient
contact tends to be lost and the intuitive concern for
privacy may be pre-empted by billing and data storage
needs. Immediate to this is a computerized medical record
system where a computer terminal exists at the bedside of
each patient. A11 personnel involved in the delivery of
services to this individual, from house-keeping to
physicians, enter the necessary information per their job
function directly onto the computer. The very existence of
the terminal in the patient room creates a more technical

environment for the patient. (Not to mention the other

6
equipment that already exists for the monitoring of the
patient’s medical status, particularly in the Intensive
Care Units). Also, preoccupation with the hardware, on the
part of the individual entering the data, may cause

one to focus less on the patient and more on the equipment,

even though not intentionally. Hence, the tendency exists for
depersonalization with computer usage.

A second aspect is the integration capability of
computers which poses a threat. For one, scattered pieces
of data can easily be compiled into a profile never before
possible without computers. Thus, an erroneous piece of
data, previously isolated in a manual file, can be
integrated with other data and widely disseminated. Also,
the computer facilitates increased access to data and
allows ease of access to such personal information between
and among computer users.

”In the past, hospitals could restrict access to
confidential information about patients simply by
preventing unauthorized persons from entering the
medical record area. However, with medical information
potentially available to anyone with a connected
terminal, there is a danger of multiple breaches
of confidentiality without the knowledge of the
hospital." 8

Thus, it is the amount of information available to be
stored in one place and the ease by which that information
can now be exchanged that poses a new potential problem.

The ease of this exchange of information becomes a

third aspect. A unique harm exists with the computer

7
because this exchange can take place with or without the
knowledge of the person about whom the information is and
it can take place intentionally or unintentionally.

Fourth, storage capabilities of computers make it
easier to maintain personal information. Often, it is less
expensive to store data than destroy it once on a
computerized system. This feature encourages increased data
collection.

Fifth, a University of Missouri research team found
that people tend to believe a machine before believing
their own good sense.9 Hence, technical and psychological
factors of computers aggravate the privacy problem given an
individual’s inclination to regard a computer printout as
infallible.

A study in 1973 by the Department of Health, Education
and Welfare on Besesdsi Qesegtess and the Rights 2:
Citizens, found the dangers latent in the spread of
computer-based personal data record-keeping stemming from
three effects of computers and computer-relategotechnology

on an organization’s record-keeping practices:

-Computerization enables an organization to enlarge
data processing capacity substantially

-Computerization greatly facilitates access to
personal data within a single organization and
across boundaries the separate organizational
entities

8
-Computerization creates a new class of record
keepers whose functions are technical and whose
contact with original suppliers and ultimate users
of personal data are often remote.
It was found that these three effects on personal data

record-keeping seldom occurred independently of one

another, but, in fact, were interdependent. What exists are
potentially adverse consequences for individuals,
organizations and society as a whole. These include: (1)
public fear of the occurrence of a "Big Brother" system;
(2) the loss of control over one’s privacy, where an
impersonal data system delivers personal information to
faceless users and (3) the loss of confidence in privacy
practices by data-gathering organizations.11

However, current trends suggest the application of
computer technology to health care management will be
essential in an era of cost containment, fiscal restraint
and responsibility and government intervention through
planning, financing and regulation.

This expansion in use is attributable to: (1)
increasing demands and expectations for medical services,
(2) the need for rapid transmission of data, (3) heavy
increases in the volume of paperwork concurrent with the
mandatory reporting to Federal and State governments and
(4) increases in annual hospital admissions and

12
ambulatory care services.

9
In its guidelines, the American Hospital Association

(AHA) attributes this informational upsurge to the
13
following:

-increasing complexity of medical care associated
with the growth in size and variety of professional

disciplines involved in the delivery of health care
services

-wide-sca1e use of computers in marshaling information,
processing information exchange and creating data
banks

-increasing mobility of the population with the
consequent increase in the volume of requests for
exchange of medical information

-expanding informational needs of governmental
agencies for planning, administration and

evaluation of government programs and policy-making
purposes

-progressive growth in the number of third parties
(a party other than the patient, the patient’s
personal representative, the physician or the
hospital) concerned with the patient and his medical
record. Many of these third parties are seeking
information for proposed uses, such as payment for
patient care, that are quite different from the
primary purpose for which it was collected

-increased governmental access to patient-identifiable
records and increased reporting of personal
information to the government

-increased incidence of health-related legal actions
and proceedings

-potential misuse of the authorization for
disclosure of medical information (See endnote 1)

Thus, the societal trend toward dependence on
computers for the collection, maintenance, storage,
management and analysis of patient care data appears to

present significant opportunities and positive advances in

10

the health care industry. The rise of health care teams,
the existence of third-party insurance programs and the
expanding limits of medicine appear to be a response to the
desires of people for better and more comprehensive medical
care.

However, as stated earlier, the computer can also pose
major threats to privacy and increase depersonalization in
the management of health facilities and the conduct of

research.

"As American society redefines and reorganizes its

health care system in the coming decade, it will

have to make increased use of computer technology to

manage the rivers of data that will be generated..

If the question is not whether but how such technology

will be used in health care, American Society has

one non-negotiable condition for this process: basic

citizen rights cannot be made a casuality

of technology-assisted health systems. To do so would

be to betray the tradition of Hippocrates and

ultimately to dehumanize health care itself." 14
These issues are particularly critical to the medical

record, given its content.
ENTER THE MEDICAL RECORD

The medical record consists of four types of data
concerning an individual patient: (1) personal, (2)
financial, (3) social and (4) medical. Personal information
is usually obtained upon admission and includes name, birth
date, sex, marital status, next of kin, occupation and
identification of physicians. Financial data include name

of the patient’s employer, the patient’s health insurance

11
company, types of insurance and policy numbers, Medicare
and Medicaid numbers, if any, and other information that
will enable the hospital to bill for its services. Social
data include the patient’s race and ethnic background
family relationships, life style and any court orders or
other directions concerning the patient, community
activities and other information related to the patient’s
position in society. Medical data form the patient’s
clinical record, a continuously maintained history of the
treatment provided to the patient in the hospital. Medical
data includes results of physical examinations, medical
history, treatment administered, progress reports,
physician’s orders, clinical laboratory, x-ray and
consultation reports, anesthesia and operation records,
signed consent forms and nurse’s notes.

State and federal statutes and regulations, municipal
codes and hospital accreditation standards require
hospitals to maintain medical records. Minimum content
requirements in the state of Michigan include
the following:15

-Admission date

-Admitting diagnosis

-History and physical examination

-Physician’s progress notes

-Operation and treatment notes and consultations

-The physician’s orders

-Nurse’s notes including temperature, pulse, respiration,
conditions observed and medication given

-Record and discharge of death
-Final diagnosis

12
Additionally, records of patients having surgery should
include:
-Details of the preoperative study and diagnosis
-The pre-operative medication
-The name of the surgeon and assistants
-The method of anesthesia
-The amount of anesthetic when measurable
-The name of the anesthetist
-The post-operative diagnosis, including pathological
findings
-The report of special examinations such as laboratory, x-ray
and pathology
The JCAH (Joint Commission on Accreditation of
Hospitals) requires hospitals to maintain patient care
records as a standard of accreditation. An adequate medical
record is to be maintained for every individual who is
evaluated or treated as an inpatient, ambulatory care

patient, or emergency patient, or one who receives patient

services in a hospital-administered home care program.

USERS AND USES OF THE MEDICAL RECORD

The potential uses and users of personal health
information are close to infinite. Appendix 1 illustrates
the several potential users and uses of such information,
both clinical and societal.16These include health care
providers (institutional and individual), third-party
payers (Blue Cross/ Blue Shield), private health and

government insurers, like Medicare, public health and

government agencies, employers, schools, courts and law

l3
enforcement and investigating agencies and credit

investigating agencies.

PERSONAL PRIVACY AND MEDICAL RECORDS
In their report on Eersegel Briggs! is an Isfezsstien
§9§igty, in 1972, the Privacy Protection Study Commission

stated:

”Never before have so many organizations had the
facilities for keeping available the information

that makes it possible for them to complete daily

a multitude of transactions with a multitude of
individuals, and to have relevant facts on each
individual available as a basis for making subsequent
decisions about him." 17

In 1967, the Freedom of Information Act (FOIA)
mandated disclosures of data maintained in government
files, but specifically exempted medical records from such
disclosure. Seven years later, the FOIA was followed by
the Privacy Act.

In the early 1970’s, the recommendations of the HEW
Advisory Committee on Automated Data Systems acted as a
precursor to the enactment of the Federal Privacy Act of
1974. The Commission recognized that "..neither law nor
technology now gives an individual the tools he needs to
protect his legitimate interests in the records

18

organizations keep about him." Accordingly, the Privacy Act

outlines the following principles:

-to create a proper balance between what an individual is
expected to divulge to a record-keeping organization and
what s/he seeks in return (to minimize intrusiveness)

14

-to open up record-keeping operations in ways that will
minimize the extent to which recorded information about
an individual is itself a course of unfairness in any
decision about him/her made on the basis of it (to
maximize fairness)

-to create and define obligations with respect to the uses
and disclosures that will be made of recorded information
about an individual (to create legitimate, enforceable
expectations of confidentiality). 20

Enactment of the Privacy Act codified principles to
protect privacy in the collection and handling of recorded
personal information by Federal agencies. "It marked the
culmination of many years of public and congressional
hearings and investigations of threats to personal privacy
by the acquistion of vast quantities of computerized

21
personal data by the Federal government." Since the Act
applies to all Federal agencies, it includes medical.
facilities, health insurance and payment records (like
Medicare) maintained by the government. The Act provides
guidelines for the collection, maintenance and use of
personal data including medical records, computerized and
manual.

However, numerous expectations in the Privacy Act
preclude decreased abuse in the dissemination of private
data. The Act does not apply to state or local governments
or to private agencies.

The right to control who may gain access to one’s

medical record is within state discretion, whereby the

record is the property of the hospital, not the patient.

15

Hospitals and other institutional providers retain the
right of ownership to the physical record-—paper, tape,
fiche or film--but the information belongs to the patient.
Hence, the hospital may restrict the removal of medical
records from its files or from its premises, determine who
may have access to their content and define the information
that may be disclosed. It is also the hospital that
establishes internal and external disclosure policies for
the release of information. (See Appendix 2)

Consequently, although the Constitution, and Federal
and State statutes have been instrumental in guarding
patients’ rights to privacy, significant efforts must still
emerge from within hospitals and other health-care
facilities to ensure adequate safeguards.

”In essence, directors of such institutions should view
the promulgation of standards to ensure necessary
protections as institutional responsibilities rather
than simply patient rights that require legal
enforcement." 22

Of central concern in this study is the patient right of
confidentiality, the right which receives the least

protection, yet, perhaps is most critical to the doctor-

patient relationship.

CONFIDENTIALITY VS PRIVACY
Privacy is the question of what personal information
should be collected or stored for a given function. It

involves issues as to the legitimacy and legality of

16
organizational demands for disclosure from individuals and
groups, and the setting of balance between the individual’s
control over the disclosure of personal information and the
needs of society for the data.

Confidentiality is the question of how personal data
collected for approved social purpose shall be held and
used by the organization that originally collected it, what
other secondary or further uses may be made of it and when
consent by the individual will be required for such uses.
Security of data involves an organization’s ability to keep
its promises of confidentiality. Individual access becomes
the issue when individuals should know that a record has
been created, when they can examine it in order to check
its accuracy, completeness and the uses being made of it.
Thus, confidentiality serves a dual purpose: it
acknowledges respect for the patient’s sense of privacy and
individuality and is important in improving the patient’s
health care.

Although there are no doctrines of confidential
communications under common law, it is accepted that
information contained in the medical record is private and
personal, therefore confidential. It then becomes the
responsibility of hospitals, in general, and the
medical record departments, in particular, to establish
appropriate policies and procedures for safeguarding

confidential information of the patient.

17

In 1979, three bills were introduced to Congress
specifically addressing the issue of confidentiality of
patient medical records, patient right to access their own
medical records and the right to make corrections in the
record.23 (See Appendices 3A,3B,3C)

With the advent of computerization in health care,
national medical associations have recognized the potential
for confidentiality to be compromised. Virtually all major
health professional groups, including the American Medical
Association (AMA), the American Hospital Association (AHA),
the American Nurse’s Association (ANA), the American
Psychiatric Association (APA), the American Medical Record
Association (AMRA), and the American Psychological
Association, have adopted formal codes, guidelines or
policies regarding the handling of health records.24
(See Appendix 4) Additionally, public interest groups are
moving into the area of citizen rights and medical
records. One such group is the People’s Medical Society, a
non-profit organization with direction and support from the
American Bar Association, Yale University, Northwestern
University and the National Women’s Health Network. In the
state of Michigan, the Department of Public Health provides
consumer education as it pertains to health and medical

issues. Target audiences include senior citizen groups, and

local health and medical facilities (See endnote 2).

18

Perhaps the most significant and prevailing sources
of privacy and confidentiality rights remains in these
codes of ethics rather than the law. It is the
responsibility of the hospital and physician to assure a
patient’s legitimate expectation that confidentiality is
not breached as a consequence of negligence by health care
professionals or the facility.

Hence, more than the traditional single-sentence oath
of confidentiality by the physician is required today. The
computer-assisted management of medical information
augments the need for guidelines for physicians, hospital
and others, with the patients receiving additional
protection. This is especially critical today where the
greater participation of sub-specialists in patient care
requires more people having access to medical records.
Although automation is not responsible for medical
specialization, the gathering of scattered medical data
into a single computerized record may create new problems.
Thus, the efficiency of automated systems makes the
potential violations easier, in this writer’s opinion.

Although individual state laws may make health
professional-patient relationships privileged to varying
degrees, and constitutional arguments and court decisions
tend to favor privacy rights, ethical mandates appear to
provide the most instrumental force for ensuring them. For

those not bound by strong ethical codes of practice and

19
high professional standards, no other guarantees can be
assumed for the present.

Thus, the need to maintain confidentiality is widely
recognized as an ethical obligation, as part of the implied
contract in the doctor-patient relationship. Unfortunately,
in real life, the doctrine of confidentiality of medical
records often is forced to give way to other public

interests--medical, legal or social.

RESEARCH QUESTIONS

Studies in the early 1970’s focused on empirical
analysis and legislative inquiries regarding the effect of
computer use by organizations and its impact on citizen
rights, including confidentiality (see Endnote 3). The
National Academy of Science studied computerized databanks
in American society with inquiries and analyses made
regarding the fundamental right between an individual’s
right to privacy and society’s right to know.25 Critical to
any policy development is the identification of the
standards to be implemented if society is to realize
benefits from information technology without jeopardizing
confidentiality.

Westin concludes in a study on privacy and health data

systems:

"The 1980’s will be a period in which general principles
for ethical health data systems are applied in both
legislation and registration rules and organizational
policies. A broad concensus seems to have developed

20
around the general principles, but this leaves a great
deal of work to apply the principles to conflict-of-value
situations:to balance the interests of patients,
professionals and organizations, and to safeguard the
trust of persons in the health care system upon which all
medical creative action animates those with responsibility
in the health care field. The '80s can see major strides
forward in both computer assistance to health care and
protection of individual’s rights." 26
Against this backdrop, three research questions emerge.
1. Are traditional laws and organizational policies related
to confidentiality keeping pace with the automation of
health information?

2. Are there appropriate usages and maintenance of
confidentiality with the automated medical record?

3. What are employee and management concerns and priorities
with (l) the existing system and (2) with a fully
automated, computerized medical record system?

Of particular importance to this study is the
determination of whether citizen rights, specifically
confidentiality, emerge as a concern and/or priority with
the automated system. Or do other priorities take
precedence to this right when policy decisions are being
made, as this writer believes. It is also hypothesized
that management and employees are functioning in an
environment that demands quick response and relay time of
this data, thereby influencing their priorities, with
confidentiality becoming a secondary concern. Several
factors may influence this: the amount and type of training
on the computer, the reliability of the hardware/software,

the degree of user-friendliness of the software that has

been either configured from another package or developed

21
in-house for that particular facility’s needs and whether
computerization assists in medical record personnel job
function. Clearly, any one of these factors could
overshadow the recognition of any potential harm promoted
via computer use and the breach of confidentiality. Given
the responsibility placed upon each individual hospital
facility to adopt policies safeguarding such rights, it
becomes critical to incorporate these rights at the onset
of any policy-making. It is proposed here, however, that,
first, organizational policy does not change appropriately
to meet the changing technologies and the potential harm
that may accompany them. Rather, old policy (in this case
policy developed for the use of the manual record) is
configured to a new technology (the computer). Secondly, it
is proposed that, management and employee concerns,
although justifiable, do not include citizens’ rights
issues due to the dynamic at work in this setting. Finally,
it is proposed confidentiality will be guarded only to the

extent that it is with a manual system of record-keeping.

METHODOLOGY
Telephone surveys were conducted with the medical
records departments of 14 midwestern hospitals. The
director and/or assistant directors in the medical records
departments were interviewed. At the request of management,

staff were not interviewed directly. One hospital did allow

22

TABLE 1: HOSPITAL SIZE

EBIEAIEZBHELIQ NUMBER OF BEDS

 

 

 

small medium large TOTAL
(0-250) (251-500) (501-1000)

PRIVATE 2 3 0 5

PUBLIC 3 5 1 9

TOTAL HOSPITALS ____
SURVEYED 14

23
an employee to answer the questionnaire. However, it should
be noted this employee was the acting supervisor in this
facility when needed. In the event the director/assistant
director was unable to answer the questions pertaining to

the computerized system (i.e.: hardware, software, storage

and access), the supervisor/ director in the Data Processing
Department provided the information.

Two urban hospitals were randomly selected from each
of the following cities: Jackson, Ann Arbor, Lansing,
Kalamazoo, Grand Rapids, Battle Creek and Detroit. These
sites were selected since they had been notified by the
Southwestern Michigan Medical Record Association of the
ULTICARE system that was being implemented at an area
hospital. ULTICARE is the first in-state fully-automated
medical record system, utilizing computer terminals at the
patient bedside. A mix of 9 public and 5 private hospitals
resulted, all non-profit facilities, ranging from 75 to 888
beds. (See Table 1) The survey was composed of open-
ended questions addressing four principal areas: 1) the
nature of the existing medical records system, 2) access
and security, 3) release of information and 4) management
of employee concerns and priorities. (See Appendix 5)

1. The nature of the existing medical records system: In
order to determine if traditional laws and organizational
policies were keeping pace with the automation of health

information, it was necessary to document the nature of the

24
existing system. Questions were asked on the type and
amount of information that was placed on computer, how and
who uses this information to determine the release of
information requirements and whether procedures exist
regarding who was authorized to manipulate this data. To
this end, who makes this policy and whether it was adequate
to accomodate the new technology can be assessed.
2) Access and Security: These questions were included to
document whether appropriate usage and maintenance of
confidentiality did exist, without any mention of
confidentiality as a central concern of this study. Again,
whether the policy in this area changed with the computer
was assessed. Questions were asked regarding the location
of the computer facility, whether it was a limited access
area, what hardware and software was used, whether the
computer facility was a private in—house system, if dumb
and/or personal computers were used, who had access to the
system, what were the back-up measures and methods of
storage and who rendered the policy in these areas.
(3) Release of Information: Legal, regulatory and accrediting
requirements for the release of information were uniform
and without change across all 14 hospitals. These
requirements were discussed in the previous chapter and
were not surveyed. However, the questions remained as to

the internal and external requests, and the documenting

25
of any changes in this policy given the easier accessibility
to a computerized system.
The questions to management regarding management and

employee concerns and priorities were specifically designed

to be open-ended. A major goal of this survey was to see if
confidentiality would emerge as a priority and/or concern
on behalf of management. To this end, confidentiality was
not mentioned at the onset of the interview. By utilizing
this method, a list was compiled of those
priorities/concerns as stated without any prompting on the
part of the interviewer. This method was chosen so that the
importance, or lack of importance, regarding
confidentiality could be assessed more objectively. Once
the open-ended questions and answers were exhausted,
confidentiality was presented as an area of interviewer
concern. Any response to this was recorded. A scenario in
question format was then presented to the interviewee
whereby their number one problem/concern was cited and
consequently challenged as it related to confidentiality
(ie:"Would you agree to an increase in down-time if it
decreased confidentiality problems?") In conclusion, the
interviewee was asked where on a priority list did
confidentiality fall: high, medium or low.

The interviews provided an exploratory "needs"

analysis and assessment by management and their employees

26
in hospitals where automation in medical records is
occurring. The profiles of each hospital served a two-fold
goal as part of this study: (1) to assess the priorities
and concerns of management and employees given a
computerized medical record and (2) to document whether
confidentiality would arise as a concern without
interviewer prompting. Documentation of the nature of the
existing system can provide the reader with the breadth
and depth of the information used and by whom, suggesting
the need for confidentiality to be maintained and guarded
during policy decision-making. The documentation of
hardware and software used, training, number of terminals,
size of hospital, private versus public facilities and
number of years on-line were included so as to assess any
comparisons between hospitals interviewed and their
responses regarding confidentiality. The indirect approach
to assessing confidentiality was achieved and done with the
hope of confirming the writer’s belief that (1) traditional
laws and organizational policies are inadequate
to meet the new flows and uses of health information and
(2) immediate concerns with the technology displaces citizen

rights in the initial designing phases.

27
FOOTNOTES

1

Beeordei gosegtsrs sad the Rights of Qitizeasi Report of
the Secretary’s Advisory Committee on Automated Data
Systems, US Department of Health, Education and Welfare,

1973, p. v.

2
Dizard. Wilson. Jr. The Qosias Isfarsstios Axe; Lonsnan
Publishing, New York and London, 1982, p. 3.

3
Ibid., p.6.

4
Williams, Frederick. The Communication Revolution. New

American Library, New York, 1982, p. 237.

5
Besordsi gesesters and the Rights of Qitizsssi Report of
the Secretary’s Advisory Committee on Automated Data

Systems, US Department of Health, Education and Welfare,
1973, p. 8.

6

Hiller, Marc and Lee Seidel. ”Patient Care Management
systems, Medical Records and Privacy: A Balancing Act,"
Eshlie Eeslth genesis; 1980. p. 332-

7
Ibid., p. 12.

8
Worthly. John. Esossiss Qosesters in goals! gore; Aupha
Press, Michigan, 1982, p. 194.

9
Tomnick, Lois. ”Electronic Bullies,” Psychology Today,
1982, p.10.

10

Westin. Alan. Semestersi Eeslth Regards sad Qitizees
Rights; US Department of Commerce, Washington, D.C., 1976,
p. 12.

28

11
Records; 92222322; 999 the Rights of Qitizepsi Report of
the- Secretary’s Advisory Committee on Automated Data

Systems, US Department of Health Education and Welfare,
1973, p. 10.

12
Hiller, Marc and Lee Siedel. "Patient Care Management

Systems, Medical Records and Privacy: A Balancing Act,"
prlie Eeeltb Reports. 1980. p. 333.

13
Béiégéé'éi'fiééiééi'1éiéiéé:i§§l"iié¥ic§3 ESESEtEI """""
Association, Chicago, 1972, p. 1. ~ '

l4
Westin. Alan- Qoppptersi Eeslth Regards sad the Rights of
Citizens. US Department of commerce, Washington, D.C.,

1976, p. 10.

15 *
Roach, William, Susan Chernoff and Carole Eisley. Madidai
Records and the Law. Aspen Systems Corporation, Maryland,

1985, p. 252.
16

§£§£ssept 2: the lisiiééi”Eséiééi'BEEEEE-léééEigiiéél’lfifii.
Chicago, 1983, p. 5.

17
Ibid., p.5.

18

Publishers, New York, 1979, p. 206.

19
32922921 Qospptezs and the Rights of Qitizepg; Report of
the Secretary’s Advisory Committee on Automated Data

Systems, US Department of Health, Education and Welfare,
1973, p. 20. -

20

Hiller, Marc and Lee Seidel. "Patient Care Management
Systems, Medical Records and Privacy: A Balancing Act,"
£22112 £99139 Reports; 1980. p. 336-

29

21
American Hospital Association. iaatitatidaai gaiigiaa fag

the Dieeleeere of Medieel Reeere Infereetiee; AHA. Chicago.
1962, p. 1.

22

Hiller, Marc and Lee Seidel. "Patient Care Management
Systems, Medical Records and Privacy: A Balancing Act,”
Beelie fleelth Reports; 1980. p. 334-

23
Waters, Kathleen and Gretchen Murphy. Madigai BSQQEQé id
Health Information. Aspen Systems Corporation, Germantown,

Maryland, 1979, p. 313.

24
Unites! Beelte Qere Infereetiee set; National Conference
of Commissioners on Uniform State Laws, 1985, p. 2.

25

Westin. Alan- Deteeeeke in 9 Free Seeietx; Qeeeeterei
Computer Databahk; EF‘EEE Computer Science Engineering
Board, National Academy of Sciences, New York Times Co.,
1972, p. v.

26

Griesser, G., J.P. Jardel, D.J. Kenny, and K. Sauter. Daia
Ereteetiee in Eeelte Infeeeetiee §xeteeee Ehere 22 He
Siaadg North Holland-Amsterdam-New York-Oxford Publishing,
1983, p. 6.

30
ENDNOTES

1

A survey of California Psychiatrists indicated that 89%
had been asked for medical information by insurance
companies, 56% by schools and 49% by employers.

Ware, Willis. "Old Practices in a New Age Endanger
Information Privacy." Haapiiai, 1977, p. 134.

2

The People’s Medical Society is a public interest group
based in Emmaus, Pennsylvania but expanding nationwide. No
centers currently exist in the state of Michigan. A
newsletter is published bi-monthly by this non—profit, tax
exempt organization. Direction and support include: the
American Bar Association, Yale University, Northwestern
University, Health Resources Center and the National Women’s
Health Network.

3

In 1976, the Institute for Computer Sciences and
Technology sponsored the study seepeterei Eeelth Beeeree
add gitiaaa Righiai The project was funded jointly by the
National Bureau of Standards and the Federal Privacy
Protection Study Commission. On-site visits of six health-
care organizations using computers to handle personal
records were studied vis-a-vis organizational policies and
computerization effects on citizen rights.

Overall, the study found health data systems expanding
without sufficient consultation in advance with groups
representing citizen rights and doctor-patient relations.
Most data systems lack analysis of how much/what kind of
personal data is need to perform their job function. Most
systems inadequately define standards of confidentiality,
controlling uses of data and release of information. Few
organizations have procedures permitting patient access to
their medical records.

In regard to computer use, the main conclusions (as of
1977) was that automation was extensive but centered on
administrative and laboratory applications and that such
effects have encountered problems with cost justification,
overcoming professional opposition to computers and
competing for funds with other social programs.

Chapter 2: The Utility of Computerized Systems

'Results

The results will be presented by section, following
the same order in which the questionnaire was administered.
Appendix 6 presents the profiles of each of the hospitals
surveyed.

HAIHEE 21' the EXI§TIE§ §X§I§H

The information abstracted from the medical record and.
placed onto computer was uniform across the fourteen
hospitals, regardless of software used. This included:

(1) patient demographics: age, ethnicity, gender, religious
affiliation and admission and discharge dates and patient
identification numbers. The patient’s social security
number was never used as an identifier. (2) patient care
data: diagnosis, theraputic procedures, including labs,
medications and x-rays and physician(s) involved.

Statistical studies and research, physician use, and
quality assurance and administrative uses were the most
cited reasons for how data were used (see Table 2). Six
facilities cited uses for billing purposes and DRG’s (see
Endnote 1). One hospital mentioned use of data for auditing
purposes. The users of this data paralleled how the
data was used. Administrators were cited as the most

31

32
TABLE 2: COMPUTER USAGE*

Uses of Data

 

 

 

Private Public Total

n=5 n=9 n=14
Audit I l 0 1
Administration I 5 7 12
Billing I 1 5 6
Research/statistical I
studies I 5 7 12
Physicians I 4 7 ll

H§§B§
Private Public Total
n=5 n=9 n=14

Administrators I 5 8 13
Physicians I 4 6 10
Research/CPHA I 4 7 1
Third Party I 0 l 1
Health Professionals I 0 3 3

Private Public Total

n=5 n=9 n=14

Passwords‘ I 5 9 14
Identification £s I 5 6 11
Security Codes per I 0 4 4

job function

33
frequent users of this information by thirteen hospitals
(see Table 2). Eleven facilities mentioned researchers as
users. This included CPHA (The Commission of Professional
and Hospital Activity) whereby eight hospitals participated
with CPHA in its research and statistical analysis of this
data by utilizing their software package, PAS Plus. Three
hospitals mentioned ancillary users of this information,
including nurses, allied health professionals and social
workers. Only one hospital mentioned third-party payers.
However, information from the abstract is not directly
directly relayed to third-party use. Therefore, it is not
so surprising that the other facilities neglected to mention
such users since they do not access this information
directly from the medical record departments, like those
previously cited.

In each case, the users (excluding the third-party
payer) directly obtained data via the medical record
department. The director of the medical record department
authorized access based on need to use and certificate of
need. Each of the hospitals continued to provide
photocopies of this information to the user. Two of the
hospitals released the information utilizing computer
printouts if the requested information was a statistical
summary and not indepth information.

Procedures regarding who was authorized to add, delete

and/or change information once on a computer file was

34
determined exclusively by the medical record department
personnel. Hence, in each facility, those employees
involved in transcribing and coding the manual record were
now allowed access to the computerized system to make
appropriate changes. Consequently, no policy changes
occurred in this area with the computer.

All hospitals employed the use of passwords. Passwords
were changed as frequently as every thirty days to every
twelve months. Over three-fourths of the hospitals used
identification numbers as additional security measures.
Four of the hospitals, in addition to the above, used
security codes per job function as one more level to secure
and limit access. Thus, the changes in policy with the
computer were procedural (see Table 2).

The median number of years on the computerized system
was five years. One hospital was on-line since 1953; two
hospitals just went on-line in 1985. The new on-line
hospitals are publically owned and categorized as small

facilities (less than 250 beds).

A§§§§§ end 5.3991311!
Table 3 presents the nature of the computerized record
systems at each hospital. Five of the hospitals have the
computer facility (mainframe) housed within the the

hospital and five in a facility outside of the hospital

itself. Four hospitals have the mainframe in

35
the same building but not in the medical record department
itself. In each case, the CRT’s used for abstracting
records were in the medical record department, qualifying
as a limited access area.

IBM was the most frequently cited hardware used by 10
hospitals. Three utilized Data General and one facility
utilized Burroughs. The most frequently used software was
PAS Plus, a software package developed exclusively for
medical record abstracting by CPHA in Ann Arbor. Two
facilities developed their own package, configured to
specific hospital need. One was a medium-bed sized private
facility, the other a public hospital with the bed size
exceeding 800. The remaining hospitals utilized software
packages offered by different computer vendors. Madgag,
utilized by one private hospital, was designed for medical
record abstracting and configured so as to send the data on
each patient to CPHA for statistical studies. iaiagz
adaaiaia Haaiia Qagai out of Salt Lake City, Utah, was
utilized by one hospital due to its compatability among its
sister hospitals. Daia gaga was a software package designed
to accomodate an entire HIS (Hospital Information System),
gdaigdi, out of Florida, was developed for medical
abstracting but includes additional features (”option

fields") for specialized in-house studies to be performed.

The last three software packages were utilized by public

36

TABLE 3: COMPUTERIZED RECORD SYSTEMS *

 

Private Public Total
n=5 n=9 n=14
Eeeeies
Medical record department I 3 2 5
Outside med-rec department I 1 3 4
Outside hospital I l 4 5
Rereeere
'Burroughs I l 0 1
IBM I 3 7 10
Data General I 1 2 3
§e£tee£e
MedRec I 1 0 l
PAS Plus I 3 5 8
Developed in-house I 1 l 2
Dynamic Control I 0 l 1
(Data Care I 0 1 l
Intermountain Health Care I 0 l l
Tessieele
Dumb I 4 8 12
Personal Computers I 1 2 3
Average number terminals I
in medical records I 10 55 65
Ireieies
In-house staff I 2 3 5
Software Company I 3 0 3
Both I 0 6 6
Beliexzsekins
Medical record department I 3 4 7
Data processing I 0 3 3
CPHA & medical records I O 2 2
Medical records & data I 2 0 2

processing

*n=14 facilities

37

facilities. In each case, the software was designed
specifically to accomodate the minimum requirements
for abstracting information from a medical record. Each
hospital had a private in-house system without outside
access to the computerized database available. It should be
noted, however, that the PAS Plus software is designed so
that an individual’s password to their facility allows them
access to another facility’s medical abstracts providing
both institutions have the same equipment, software package
and the ARDOS operating system.

Two of the hospitals utilized personal computers for
their abstracting, the remaining were equipped with
dumb terminals. One facility utilized both a personal
computer and dumb terminals, but the PC was used strictly
for word processing, not medical record abstracting.
There was a total of 65 terminals in the medical records
departments in the 14 hospitals surveyed. There was one-
fifth the number of terminals in the private facilities
compared to the public hospitals. However, the number of
terminals did not necessarily parallel hospital size, in so
far as the larger the facility the greater number of
terminals employed. (One or two terminals existed in
hospitals of bed size 75, 137, 209, 210 and 510 and 12'
terminals were available in a hospital with 888 beds).

Responsibility for employee training varied between the

medical record staff and the software company. Five

38
hospitals trained their employees themselves; three
facilities had the computer vendor supplying the software
do the training (in this case CPHA, with PAS Plus being the
software used); and six facilities were involved in a joint
effort between the department staff and the software
company (Table 3).

In all but one case, the backup and storage measures
involved a nightly taping of the information; one facility
placed and stored their information on disk. Access to
these tapes was restricted to the transcriptionists and
080’s in each department. Policy in this area was made by
the medical record department in half of the hospitals
surveyed (Table 3). In the five hospitals where the
mainframe was housed outside the hospital, data
processing rendered the policy, in each case
publically owned facilities. The remaining four hospitals
were divided in their policy making in this area with joint
efforts between CPHA and medical records or medical records

and data processing (Table 3).

E§L§é§§ 9.! INEQEMAIIQ!
Responses concerning release of information procedures
for legal, regulatory and accrediting requirements were
uniform across hospitals. Internal and external requests

for information were handled by the director of the Medical

Record Departments in all 14 facilities.

39
Again, in each hospital surveyed, none of these
requirements and/or regulations were cited as having

changed with computerization.

MAHAQEMEETZEMELQXEE QQHQEEN§ end BBIQEITIE§

Answers yielded in this section were categorized as
being hardware issues (areas of priorities/concerns
relating to the actual equipment), software issues (areas
of priorities/concerns relating to the package and what it
offers in terms of services), or other (areas of
priorties/concerns not directly relating to hardware or
software issues). This categorization was not planned prior
to the administration of the survey but rather emerged
based on those answers given to the open-ended questions.

The data was then compiled and tabled.

EXI§IIHQ §X§I§Mi EBIQBIIIE§ZQQKQEBH§

Table 4 presents the priorities and concerns by
management and employees given the existing system. Again,
management reports these priorities and concerns for the
employees.

Hardware issues were cited most often as
priorities/concerns both by management and employees. For
management, having the computer assist in time-saving

functions was the top priority given the existing system,

40

TABLE 4: MANAGEMENT & EMPLOYEE PRIORITIES
WITH EXISTING SYSTEM *

Management Employee Total

Eereeere

time saver I 4 2 6
retrievability I 3 l 4
backloading I l l 2
downtime I l 1 2
screen problems I l 1 2
losing data I 1 l 2
storage I l l 2
time lapse between screens I 0 2 2
keyboard I 0 2 2
Softeere

networking/interfacing I 5 l 6
duplication/time loss I l 2 3
comprehensive I l 0 1
error rate I 0 l 1
ches

monitoring data I l 0 1
accuracy I l 0 1
quality control I l 0 1
over employee I

training I 0 l l
implementation I 1 0 l
ease of system I l 0 1

*n=l4 facilities

41
TABLE 5: MANAGEMENT & EMPLOYEE PRIORITIES
WITH A FULLY-AUTOMATED SYSTEM 1

Management Employee Total

Regenere

retrievability I 2 0 2
‘backup I 2 0 2
downtime I l l 2
storage I 1 0 1
time saver I l 0 1
screen problems I 0 1 1
§e§tee£e

interfacing I l 0 I
own package I l 0 1
cher

training . I 6 1 7
physician cooperation I 3 0 3
accuracy I 2 0 2
security I 2 0 2
confidentiality I 2 0 2
improve working I l 0 1

conditions I

money I 1 0 1
position displacement I 0 1 l
reliability I l 0 1
time frame I l 0 1

*n=l4 facilities

42

followed by retrievability: having quicker and easier
access to the data. Other hardware concerns included
backloading, storage concerns, problems with downtime,
screen problems on the CRT and losing input due to computer
shut-down. Software issues were having the software
interface with more departments throughout the hospital, as
cited by five facilities. Software configuration to
decrease the amount of duplication of screens and a package
that was more comprehensive so more could be done with the
data were priorities cited by at least one facility. Qiha;
issues, as cited by at least one hospital, were
accuracy, monitoring the data, having quality control over
the employee, implementation concerns with the computer and
the ease of manipulating the data for research purposes.

Employee priorities/concerns, as offered by management,
focused on hardware issues. Problems with learning the
keyboard, time-saving functions and the time lapse between
screens were cited at least by two hospitals. Software
issues were cited less often as concerns, with duplicaton
of screens and subsequent time loss on the system due to
software configuration as the major concerns. This was
followed by the limitations of the software due to the lack
of interfacing between departments in the hospital, thus
involving duplication of input. Less error rate, due

to the software alerting the transcriptionist when an

43
error was made, was cited once. Adequate training of the

employee was mentioned by one facility.

Elli-LI AHIQMAIED. §X§IEM£ BBIQBIIIEZQQL‘QEBM
Prior to documenting any response, the interviewee was

asked whether they were acquainted with the fully
computerized system now in effect at a hospital in
southeastern Michigan. The ULTICARE system at this
facility is state-of-the-art and suggestive of the trend
toward fully automated medical record systems. Integral
to such systems is having a computer terminal at the
bedside of each patient. Public relation representatives
had discussed this system in those geographic areas
contacted for this survey.

Table 5 presents the priorities and concerns by
management and employee given a fully-automated medical
record system.

Approximately two-thirds of those issues mentioned as

priorities/concerns were in the area other than hardware or
software. Management cited adequate training as the
greatest priority and concern given a fully automated
system. Having physician cooperation in this endeavor was
second in priority, with such cooperation cited as "making
or breaking" a fully automated HIS. Other issues cited were
accuracy, security, confidentiality, adequate time frame to

implement, adequate monies to implement, reliability of the

44
system and having a system that would improve working
conditions. Hardware issues cited were retrievability of
the information, backup of the information, storage
capacity, downtime and having the system set as a time-
saver. Interfacing among departments and developing one’s
own software package given a fully automated system were
cited as software priorities.

Management was less able to address employee concerns
given the context of a completely computerized system.
Downtime and the time lapse between screens were cited as
hardware issues; personnel position displacement due to the
computer and training were dihag priorities. Ten hospitals
gave a "don’t know" response.

Two hospitals, privately owned, cited confidentiality
as a priority/concern without interviewer prompting. Given
the scenario whereby a compromise was suggested between
their number 1 concern and confidentiality, 8 hospitals
(57.1%) said they would place confidentiality as the

priority; 4 hospitals (28.5%) said they would not and 2
hospitals (14.2%) gave a "don’t know” response (See Table
6). Confidentiality was rated as a high priority by 12 of
the 14 facilities, the remaining two said it was a medium
priority. Prior to responding to all of these questions,
50% of the hospitals were familiar with the fully-
automated, computerized medical record system, ULTICARE

(Table 7).

45

TABLE 6: CITIZEN RIGHT PRIORITY and COMPUTER KNOWLEDGE

SCENARIO **

xee 29 erg
PRIVATE (n=5) 3 1 1
PUBLIC (n=9) 5 3 1
TOTAL (n=14) 8 4 2
"""mEZQEEXQ’EEQ """"""""""""""""""""""""""

ULTICARE (n=7) 3 3 1
NOT FAMILIAR 5 1 1
WITH ULTICARE (n=7)

TOTAL (n=14) _ 8 4 2

*1 A scenario in question format was presented to the
interviews whereby their number one concern/problem was
cited and challenged as it related to confidentiality (ie:
”Would you agree to an increase in downtime if it decreased
confidentiality problems?")

46

TABLE 7: CONFIDENTIALITY PRIORITY

PRIORITY
low medium high
Private (n=5) I 0 0 5
Public (n=9) I 0 2 7
Total (n=14) I 0 2 12

47
DISCUSSION

Overall, many aspects of this study yielded uniform
responses between the 14 hospitals surveyed. What
information was abstracted, users and uses of this
information and how this information was obtained provided
the scope in nature and amount of information used
supporting the necessity for guarding confidentiality. The
procedures that existed for authorization to add, delete
and/or change information had not changed at all with the
advent of the computerized system, but rather old policies,
as they applied to the manual system, were used
across the 14 hospitals. The policy in this area was
rendered exclusively by medical record personnel.

Although only two hospitals cited confidentiality as a
priority/concern, procedural changes, with the use of
passwords and identification numbers occurred, suggesting
confidentiality was guarded. Four hospitals, in addition to
the above, employed security codes per job function as one
more level to secure and limit access. However, these four
hospitals, all public facilities, did not cite
confidentiality as a priority/concern; one of the four
rated confidentiality ’medium’, as opposed to 'high’,
on a priority list in addition to placing confidentiality
second to their number one priority of interfacing

software. Yet it was two private facilities that stated

48

confidentiality as a first priority. Patient names were
never used on the abstracts. Patient number identifiers
were never social security numbers, therefore making it
more difficult to trace a patient’s chart. All terminals
were in a limited access area with only authorized
personnel being able to access the system and all were
private in-house systems. However, the PAS Plus software
package, and its network with the ARDOS operating system,
as utilized by eight of the hospitals, is designed so that
an individual’s password to their facility allows them
access to another facility’s medical abstracts nation-wide,
providing both institutions have the same equipment and
software. The software package out of Florida, utilized by
one hospital, is configured so that the vendor can access
the system. These two situations outline the pgiaaiiai hag!
that exists with the basic citizen right of confidentiality.

To this end, appropriate maintenance of
confidentiality appears intact, even though only two
hospitals cited it as an issue of concern. In this sense,
confidentiality was a serendipitous beneficiary of computer
security practices. If there was any inappropriate usage,
it seems that it was not due to the automation but rather
to the changes in the health care industry as a whole (ie:
more third-party payers and administrators requesting the

information). Three of the hospitals stated that with such

49
changes, the medical record abstracts were under more
critical and acute observation.

Consequently, traditional organizational policies
appear inadequate to meet the new flows and uses. Only two
of the hospitals provided a computer printout. Xeroxing of
hard copy is prevalent. Given the number of users- from
physicians, researchers, ancillary medical personnel and
administrators- it would seem more than the medical record
department personnel should be involved in the
authorization of who adds, deletes and/or changes
information on a computer file. None of the
directors/assistant directors gave any indication that with
the change-over from the manual to the computerized system
employees were alerted to the potential harm that exists
with easier access to such a system and the consequent
breach of confidentiality. Only one hospital cited that the
sharing of passwords was discouraged among employees,
although all stated that breach of confidentiality, as with
the manual record, was grounds for dismissal. Other than
the procedural changes which took place, manual record
policies were utilized. This included any physician or
adminstrator the ’right’ to access information on a demand
basis. Although "need to know" and ”certificate of needs"
are required before any release of information, none of the

hospitals, when asked, refused a request. Seven of the

50
eight hospitals utilizing the CPHA software package did not
know how the information was used for statistical research
or how confidentiality was maintained once CPHA obtained
the information.

Concerns with the technology were prevalent among
management and employees given their existing systems.
Networking and interfacing the existing system to remote
locations throughout the hospital, so as to include more
functions outside the medical record department, was most
frequently cited as the main concern/priority among
management and employees. This appears contrary to the
fact that only medical record personnel are currently
involved with the existing policy-making in the
authorization of using information on a computer file.
Additionally, two of these five hospitals said that
confidentiality would rate second to networking if given
the choice, thus supporting this priority.

Having the computer assist with time-saving functions
was the second most cited concern. Two of the facilities
had only one terminal for abstracting, which may explain
their concern. None of these hospitals were having any
computer difficulty but rather claimed the computer
facilitated short cuts, speeding-up the process of

abstracting and allowed for less paper usage, making the

51
process easier. Three of the four hospitals, however,
stated that confidentiality would rate first before time-
saving as a priority.

The third most frequently cited concern across
management and employee concerns was retrievability of
information. The speed in getting the data, immediate
access to statistics and faster retrieval were cited as
reasons, supporting the hypothesis that management and
employees are functioning in an environment that demands
quick response and relay time of this data, thereby
influencing their priorities, with confidentiality becoming
a secondary concern. However, although none of these
facilities mentioned confidentiality as a priority/concern
without prompting, each stated they would forfeit
retrievability and place confidentiality first if a choice
had to be made.

Employee concerns focused exclusively on the
technology in all but one response, in which case training
was also cited.

When presented with a fully automated system,
providing adequate training was cited most frequently as a
priority by management. Of these six hospitals, training
was currently provided by the medical record staff in two

departments, by the software company in three departments

52
and via a joint effort of the two in the remaining two
hospitals. Training was viewed as critical by one facility
since if good training existed, with confidentiality as
part of the instruction, then less problems with
confidentiality would occur in the long run. Other aspects
of the training, as cited by four facilities, involved
teaching of the hardware and software, the keyboard, how to
use the computer with login, passwords and menu, in
addition to having aaiiigiaat time to do the training. One
hospital stated information was only as good as the
individual entering the data; it was necessary for all
persons accessing the system, not just medical record
personnel,to realize the implications of incorrectly
inputting the data. Again, this supports the contention
that more than medical record personnel should
be involved in the policy-making. Also interesting to note
is that two of the four facilities addressed the issue of
training as it relates to confidentiality and four of the
facilities viewed training as critical as it relates to the
actual teaching of the hardware and software. This
suggests that concerns with technology displace citizen
rights in the initial designing phases. When presented with
the scenario of placing training second to confidentiality,
results were evenly divided, with half of the hospitals
saying training would be the first priority, the other half

of the hospitals stating confidentiality as the priority

53
over training. Additionally, three of these facilities were
private and three were privately owned,and three were
publically owned with only one citing confidentiality as an
issue without interviewer prompting. Of those placing
confidentiality second to training, two knew of the fully-
automated system at the southeastern Michigan facility, one
did not.

Doctor cooperation with the implementation of the
system was the second most cited concern with a fully
automated system. One facility stated that their
cooperation could "make or break" the entire system. One
hospital’s experience was that physicians didn’t want
anything to do with computers, but her observation was that
physicians didn’t cooperate by providing adequate time for
proper training to occur. This same reason was provided by
one other facility. It appears that physician cooperation
and training are related priorities/concerns with one
requiring the need of the other. This also suggests that by
having doctor cooperation and adequate training, with
emphasis on ethics and confidentiality, the citizen right
of confidentiality is guarded, albeit indirectly.

Interestingly, three facilities stated their greatest
concerns of breach of confidentiality were by internal (in-
house) users not external users (computer hackers, third

parties). Physicians were cited by the directors in these

54
three facilities as being the greatest abusers. Clearly,
this supports the need for training and cooperation given a
fully-automated system and in so doing confidentiality is
indirectly protected. Two of the three hospitals that cited
doctor cooperation as a priority placed confidentiality
first when given this scenario.

Interesting comparisons existed between the two
facilities that mentioned confidentiality as a priority
without interviewer prompting. Both were private
facilities, but one was a small hospital with 137 beds, the
other a 529 bed hospital. The same software package was
used by both facilities, PAS Plus without any mention of
past or existing hardware or software problems. Both
facilities utilized one dumb terminal, housed in a
limited access area. Both had been on-line since 1981 with
the software company providing the training. Both rated
confidentiality as a high priority. The smaller
facility had been without any known problems of breach of
confidentiality and rated the time-saving function of the
computer as the next priority. When given the scenario,
confidentiality took precedence to any other concern. The
other hospital did have problems with breach of
confidentiality which led to dismissal of a physician
involved. Retrievability was rated as the second priority
to confidentiality followed by doctor cooperation and

adequate training. Despite the recognition of

55
confidentiality as a main priority, the economies of
retrieving the information quickly were chosen over
confidentiality if a choice had to be made. Ethically
confidentiality was cited as a priority, but realistically
retrievability would be placed first in the policy
decision-making, according to the director in this
facility. It was stated that confidentiality problems would
be handled ”as they occurred." (This was also stated by
three other facilities). The director of this department
was on the planning committee for their system in the early
1980’s and confidentiality was not part of the process of
design but rather came up ”after the fact when (we) were
on-line." Concerns cited, as part of the planning
committee, were hardware and software issues, training and
physician cooperation.

Of the two facilities citing confidentiality, the
one without any problems of breach continued to uphold this
citizen right, whereas the facility with known problems
stated that the economies of other concerns displaced
confidentiality as a priority.

Not a direct part of this survey was attendance to
the Southwestern Michigan Medical Record Association
meeting, where two representatives from a midwestern
hospital, discussed ULTICARE, a fully computerized medical
record system. The meeting was attended by approximately 75

employees and managers of medical record departments

56
throughout southwestern Michigan. When the discussion
was opened to the audience, the following questions and
concerns were documented by the author:

downtime (including power failures)

response time

backup measures

storage

doctor receptivity/training on the system

employees displacement of position

change in organizational design with the computer (ie: the
increase in PA positions)

the nature of the change in function in the department
what happens if you don’t bring your computer card to work
er lose it (ie: card to access the system)

10. loss of information was on-line

11. how much paper will remain

12. how will electronic signatures be accepted

QODOI-hCASNI-J

com

Although security and confidentiality was one area of
seven discussed by the representatives, it was not
mentioned once in the 45 minute question and answer period
that followed. Issues and concerns regarding the technology

were more frequently cited than that of citizen rights.

CONCLUSION

Overall, the 14 profiles showed that the extension of
computing and communication by these hospitals is
essentially a matter of organizational design.
Computerization requires managers to exercise choice in
selecting files and data flows to automate, arranging
configurations of hardware and terminals, defining
operator-machine relationships, setting patterns of data-

sharing inside and outside the organization, deciding on

57
the levels of organizational monitoring and reporting, and
reviewing what types of data collection, patient consent,
‘and access-to-record rules the organization traditionally
provided and she; it sill nee prezide with
a fully automated system.1 The real locus of decision-
making as to how confidentiality will be regarded
lies with these organizational managements. However, it
appears that traditional organizational policies have not
'kept pace with the flows and uses of health information.
Despite the expansive nature of users and uses of this
information, policy regarding authorization and access is
exclusively determined by medical record personnel,
according to the surveyed results. The same practices
(pursued with manual records appears to be carrying over
into computerized files. Given the more detailed, more
centralized, more permanent, more easily transmissable
quality of computerized medical records, the policies
currently employed with respect to manual records threaten
to be seriously inadequate, even if it only pertains to the

pgtaaiiai dag! in compromising confidentiality.

It appears that computerization of personal medical
information has been marked by haphazard growth. It has not
developed according to thoughtfully conceived plans for
achieving integrated health information systems, which may
be why interfacing/networking was the most cited priority.

Immediate concerns with the technology displaces citizen

58

rights as supported by the number of facilities citing
hardware and software issues as the main priorities and
concerns. Although over 85% of the hospitals agreed that
confidentiality was integral to medical record department
function, only two cited it as a priority without
prompting. At the same time, policy as to confidentiality
appears to be developing on an individual, ad hoc basis, as
. supported by the four facilities who handled problems with
confidentiality as they occurred. Although procedural
changes occurred with the advent of computerization in the
form of computer security practices, the use of passwords
and identification numbers alone is not sufficient to guard
confidentiality. Appropriate maintenance of confidentiality
appears to be provided 59 iha aaiaai that confidentiality
becomes a beneficiary of computer security practices.
Nothing suggested that confidentiality was considered in
the initial designing phases of these systems. Whether
appropriate usage is maintained with automation is a
question that requires constant monitoring. How much and
what kind of identified personal data is really needed to
perform one’s job function is a question that demands
an entire study, far beyond the scope of this analysisr

The following chapter will discuss the policy
alternatives using the 14 profiles as guidelines.

Suggestions for future studies are also discussed.

59
FOOTNOTES

1 .

Westin. Alan. Qeepeierei Heelth Reeeree end Qitieee
Rigaia. US Department of Commrce, Washington, D.C., 1976,
p. xvi.

60
ENDNOTES

1

DRG’s: Diagnostic Related Groups: A standard applied to
length of hospital stay per categorization of disease.
Utilized for billing practices as a means to codify and
regulate health care costs.

Chapter 3: Private and Public Policy Alternatives

”The untoward effects of such (computer) systems
do not stem in the main from poor technical
security. Although public mistrust of the
computer often center on the possibility of
unauthorized access to a central data bank for
purposes of blackmail or commercial exploitation,
the purely technical difficulties that can be
placed in the path of any but the most well-
equipped intruder can make almost every
computer installation more secure than its
manual counterpart." 1

To provide a perspective for the policy analysis and
recommendations, three postulates from this study are
important:

1. It is a paramount requirement of American society,
based on its concern for human values and individual
dignity, that citizen rights (i.e., confidentiality) be
adequately protected regardless of health-care or computer
system options. The objective should be assurance of
individual right guarantees of all institutions collecting
medical information. Issues of citizen rights should not
become matters for later consideration, addressed on an ad-
hoc basis, or simply be the beneficiary of computer
security practices, but they should be integrated in the
initial designing and planning stages of policy-making;

2. Medical records and health information are used

today in a wide variety of settings. Given this great

61

62
diversity of settings, no single public-policy intervention
can be expected for standard-setting for the protection of
citizen rights, in particular confidentiality. A model
statute, judicial rule, constitutional ammendment or
manager’s code could not encompass, on its own, all the
important problems that need attention in this area, nor
would the actions of any aaa of these policy-forming
authorities be adequate in terms of regulatory supervision.
Therefore, a combination of policies and standards from
various authorities and institutions in the social system
will ultimately contribute to a consistent, national
approach.

3. From this analysis, computerized medical records do
not appear to be emerging under a set of guiding principles
and procedures. Sufficiently precise standards of
confidentiality, even if advocated in hospital guidelines,
are not adequately voiced as priorities on behalf of

medical record personnel.

CONCEPT APPLICATION TO AUTOMATED
MEDICAL RECORD SYSTEMS
In order to prevent the potential abuse of
computerized medical record sytems, both administrative
guidelines and appropriate computer systems requirements

are needed.

63

The incorporation of four major principles, offered as
administrative guidelines in a study on Health Informatics
and Privacy, are relevant to this analysis: 2

1. Basic definition of function: An understanding of
the purpose and future objectives of the computer-aided
information system should exist.

2. Rights of individuals: A clear line of
administrative responsibility concerning the interests of
confidentiality should exist.

3. Licensing and selection of employees: There should
be a careful selection of employees for competence and
integrity akin to licensing procedures within the medical
profession as a whole.

4. Code of ethics: The support of relevant
professional societies is required in establishing a code
of ethics for the centralization of health information.
Ideally, the elected representatives should enact policies
that will govern the use of such systems in the individual
and public interests.

These principles only act as a framework for
confidentiality to be integrated both ethically and
realistically into any policy decision-making with fully
automated, computerized medical records systems.

What follows is an attempt to define more specifically
those principles that would enhance the above framework

given the case study findings. A study sponsored by the

64
Institute for Computer Sciences and Technology in 1974 on
Qenpnterei Eeelth Reeende end Qitinen Rights

3
provides guidelines to this endeavor.

I. The Need To Teach Respect For Citizen Rights

Perhaps the most critical element to any assurances
that confidentiality be maintained and guarded is the
observance of a good training program concurrent with an
adequate amount of time to train the personnel. Clearly,
this was recognized by the directors surveyed for this
analysisf/The integrity of any information system regarding
confidentiality will eventually be resolved at the level of
the human factor. "Computers..are devices..an(d) inanimate
objects devised by man to receive, transfer or hold
information items made available to the system through
human intervention.”4 The predominant relationship is one
of persons to the system. Individuals are responsible for
the creation of the system, the input of the information,
the manipulation of that information and the final
disposition of the data produced by the system.
Consequently, personnel standards are necessary due to the
prime significance of the human element in the integrity of
any automated system:

(1) Personnel standards should be established for all

participants including doctors, nurses, allied health

professionals, administrators, data processing staffs, etc.

65

A careful selection of employees should exist stressing
competence and integrity.

(2) All accepted personnel should be indoctrinated on
a continuing basis regarding the system objectives,
functions and operational responsibility regarding
confidentiality. This includes the development of
orientation programs, interpretive guidelines, continuing
seminars, problem-solving sessions and annual reviews to
foster understanding of the system’s policies on citizen
rights.5 These programs should acknowledge and accomodate
the attitudes of major occupational groups in the
organization, namely physicians. Doctor cooperation and
support in this area is critical and should be encouraged,
as the findings of this study suggest. When possible,
patients and public representatives should be included in
the development, management and evaluation of these
programs. In calling for such supportive activities, the
attitudes of top management play a central role. It is
necessary, albeit ideal, that they are committed to
policies safeguarding confidentiality and not project any
attitude of annoyance or intrusions into more important
matters.

(3) Specific training should be provided regarding
terminal operation. Ideally, the company providing the
software should be involved in this training concurrent

with the management in each of the departments involved.

66
Differences did not emerge in this study in terms of
performance or acceptability of the computerized system
with the training done either by the medical record
department or in conjunction with the software company.

Having the support of the latter, however, would act as an
additional measure for proper instruction and adaptability

to the system as a whole.
II. The Need To Apply Appropriate Security Measures

Due to the sensitive nature of the information stored
in a medical information system, security measures should
exist to limit access by personnel within the hospital
utilizing a need-toeknow and/or certificate of need, (as
cited in two of the surveyed facilities), to monitor the
uses to detect unauthorized access and protect files from
outside intrusion. In this respect, several departments
should be involved in the policy making, not just the
medical record department personnel as indicated in the
.findings, since the use of this information far extends the
medical record department. The use of passwords and
identification numbers provide adequate security measures;
the use of security codes by job function, thus limiting
how much information one can access given one’s job
description, is an excellent security addition as utilized
by four of the hospitals surveyed. The sharing of

passwords, identification numbers and cards should be

67

discouraged with penalties existing in the event of its
occurrence. The key issue is the need for management across
all departments with personnel involved in accessing the
computerized system, to formulate clear policies as to data
access. The basic goal of data security was to block or
detect attempts by the hospital’s own personnel to obtain
confidential data which they are not authorized to have;
this suggestion is based on the findings that more internal
than external breaches occurred. The cost and trouble to
outsiders for breaking into the system must be sufficiently

6
high to dissuade potential intruders.

III. The Need To Insure Accuracy

As indicated in this study, an indirect insurance of
confidentiality is having managers and staff make certain
that the personal data they input and store are as
accurate, timely and complete as the uses to be made of
them require. Worth restating is that this is critical with
computerization since an erroneous piece of data can be
integrated with other data and widely disseminated. This
not only ensures an individual’s proper health care but
protects the social opportunities and benefits of
individuals that may be determined through the use of such
data.7

The basic point of this suggestion is based on the

cited priority in this study of wanting a more

68
comprehensive computerized system (ie: interfacing and
networking). The more comprehensive a hospital information
system, as would be the case with a fully automated medical
record, the more its records are relied upon, the

greater the attention that must be paid to accuracy.

IV. The Need For Outside Examination

The use of computers in the medical record departments
surveyed should not a one-time decision as to how and what
information will be automated. The ultimate manifestation
of this is one hospital’s move to diligagfi, a
fully automated medical record previously described. The
expansion of applications to additional files, new
combinations of data and more extensive data utilization,
reasons cited for a change in software packages by four
hospitals, serve as additional manifestations. This
supports the need for regular review of such systems,
ideally by and through the utilization of ethics
committees. Periodic review should focus on the continuing
adequacy of the hospital’s policies and data security in
light of the changes in data processing. More importantly,
in alignment to this study, is examination by this group of
such expansions and impacts it might have in relation to

confidentiality.

69
Good public policy requires that outside review not be
merely a one-time process, that being at the onset of
implementing a comprehensive, computerized system. Who
would conduct such reviews could be via a private
commission or association, a state regulatory
agency or a federal body.8 Of importance to this writer

is the need for ethics committees to be a central part of

this review body.

V. The Need To Secure Information For Public Use

The individual’s right to privacy and the public’s
right to examine and supervise how its institutions are
functioning, as suggested in the above, is a dichotomy that
demands attention. Given the obvious conflict, the rules of
confidentiality should be devised to avoid the existing
difficulties. Suggestions offered by Westin’s
study were to use medical records without unique
identifiers or with potentially-identifiable data removed,
thus softening the conflict between privacy and public
access interests.9 The findings showed that not one
hospital in this study used social security numbers or its
equivalent as patient number identifiers.

Traditgonal laws governing confidentiality also poses

Iconflicts. In some instances, personal information covered

bar the Privacy Act of 1974, but not required to be

70
disclosed under the Freedom of Information Act, may be
disclosed under the Privacy Act for routine uses or with
the prior written consent of the subject material. The
Privacy Act allows for disclosures in the public interest

of only certain kinds of information, while the

Freedom of Information Act allows for invasions of privacy
by disclosures of personal information if a public need is
established. Because the Privacy Act does not

supercede the Freedom of Information Act, which permits
invasion of privacy unless clearly unwarranted, there

are insufficient safeguards against the arbitrary exercise
of administrative discretion and possible invasion of
personal privacy.11 Consequently, many of these situations,
as they arise within the medical record departments, are
handled on an ad-hoc basis.

Part of this analysis was the determination of whether
traditional laws were keeping pace with the automation of
medical records. It appeared they are, at best, inadequate
given the above discussion. The task of public policy
is to install regulations as to what uses can and should be
made of personal data and establish penalties against
misuse, thus supporting public confidence in the
handling of personal information. This also indirectly.

supports confidentiality of a fully-automated medical

record.

71

VI. The Need For Patient Representation

The need to inform patients that they have rights and
how to exercise them is presently recognized, as
exemplified in the American Hospital Association’s Bill Of
Rights For Hospital Patients and the involvement of public
interst groups in this area.12 With regard to patient
rights and computers, every hospital with a computerized
medical record system should provide this information to
the patient via a handbook upon admission and/or through a
person who serves as an ombudsman representing patient
rights. This serves two purposes. For one, the very
publication of such a handbook alerts and reminds hospital
staff of its responsibilities and obligation to patient
rights.13 Secondly, and perhaps the more critical element
in supporting citizen rights, is the role and presence of
this representative. This individual, as part of his/her
duties, would explain the nature of a
computerized medical record. This allows for joint
responsibility to exist between the patient and hospital
personnel in serving patient rights, a necessity given the
consumer role individuals are facing with the changing
.health care industry. Additionally, a provision should_

exist for individuals (patients) to inspect the files

Icontaining personal medical data with the means to correct

72
any information that is in error or subject to bias

interpretation.

POLICY ACTION

The task of applying these guidelines to the
computerization of medical records requires long-range
goals that should be started before the inception of the
fully-automated system. Action should occur through a
mixture of interventions from legislative,
organizational, citizen-group and judicial initiatives.14

As hypothesized, traditional laws and organizational
policies regarding confidentiality are not keeping pace
with the automation of health records. Consequently,
legislative actions defining explicit citizen rights
provisions and a general administrative system facilitating
these rights should be developed. Ideally, public interest
groups should work cooperatively with the medical staff in
this endeavor providing a driving force for state
legislative action. Judicial action should include a broad
strategy establishing common law duty of private
organizations and the constitutional duty of government
organizations to take "reasonable care" in the handling of
sensitive, personal medical information.15 Organizational
responsibilities should include adequate training programs

‘With.emphasis on confidentiality issues. Data processing,

medical record and computer vendor personnel should work

73
collectively in developing security measures in relation to
system access and employee standards. Citizen-
group actions are central to raising citizen rights issues
and maintaining this attention. This level of involvement
may actually be the cornerstone to sound confidential
practices with a fully-automated medical record since
"..without consumer education, appropriate organizational
policies and procedures and informed up-to-date
legislation, a comprehensive and workable plan for
protecting the confidentiality of medical records

16
will remain an unmet objective."

FUTURE STUDIES

This case study is, at best, a first-stage approach to
an ever-demanding cause: "citizen rights can not be made a
causality of technology-assisted health systems.”17 This
study provides further proof, with only two of the fourteen
facilities mentioning confidentiality as a priority, of the
criticalness of properly and continually enforcing this
right.

As a consequence of this research, several ideas for
future studies in the area of confidentiality and hospital
information systems emerge:

1. Assessing computer vendor role in the development

of software packages and the measures taken to insure

confidentiality at that level of development.

74

2. Documenting physician role and understanding of the
medical record and the medical record department: what is
their level of willingness to learn the system?

3. Documenting the amount and kind of confidential
information a physician chooses not to put into the medical
record and whether computerization influences that
decision.

4. Documenting the role of the medical record in
today’s changing health care industry.

5. Documenting any change in definition of
confidentiality by patient and physician with
computerization of the medical record.

6. Assessing the type and nature of research conducted
with medical record data, how the information is used and
by whom among hospitals.

7. Documenting the trend of consumerism in the area of
medical records and the amount of consumer awareness vis-a-
vis patient rights and access to one’s medical record.

Although this case study provides a starting point for
future, more in-depth analysis of such issues, it has areas
of weakness worthy of discussion.

A larger sample size would have yielded better data
for statistical tests of significance. T-tests could have
been run testing for significant differences between
private and public facilities, hospital size, the

nature of the existing system and access and security

75
issues in relation to answers given regarding
confidentiality. A sample size of fourteen limits the
discussion to a qualitative, exploratory analysis. Clearly,
a larger sample size would make for better generalizability
of results.

The procedure of asking questions regarding the nature
of the existing system first, followed by access and security
issues, may have led the respondent into a technical mind-set.
Consequently, this may have influenced the nature in which
the open-ended questions were answered regarding
priorities/concerns with the existing system and given a
fully-automated record. This may explain the abundance
in nature of technical (ie: hardware and software) issues.

Another area of weakness in the study was having
management respond on behalf of the employees. Ideally, the
questionnaire should have been answered by both the staff
and management thus adding credibility to the list of
employee priorities and concerns.

Two areas of concern emerged from this study. Whether
they can be attributed to areas of weakness in study design
are speculative.

One area was that policy regarding authorization and
access was stated as being exclusively determined by
medical record personnel. However, per the American
Hospital Association’s guidelines on the internal and

external disclosure policies of such information, hospital

76
administrators establish the policy, not just medical
record department personnel. Whether the discrepancy lies
in the nature of the question and how it was aked, thus
biasing the interpretation and subsequent answer on the

part of the respondent, or whether the policy as outlined

in the guidelines is not be followed remains unanswered.
One can only specualte the real reason. If it is a question
of not adhering to the guidelines, then action is necessary
to remedy the problem.

The second area of concern was that none of the
hospitals cited "patients" as users of the medical record,
despite Michigan state law allowing patient access to
hospital records and those records kept at doctors’
offices. Here again, whether the nature of the question
influenced respondent answer, thus not mentioning patients
as users, or the departments are not getting such requests
by the consumer to begin with, is cause for specualtion.

Since its founding in 1928, the American Medical
Record Association has been committed to high ethical
standards with confidentiality as one of its highest
priorities. Because confidentiality is ‘such a given’ and
so central and integral to medical record department
function may explain why it was not mentioned as a
priority. Conversely, this may actually provide further
support to the contention that technology displaces citizen

rights; the long-standing tradition of ethical commitment

77
to confidentiality needs to be more than an assumed
priority with the advent of a fully-automated medical
record.

It is worth restating that this study, in its
conclusion, does not assert citizen rights are in greater
jeopardy today with the advent of computerization. It is
believed by the author it is the potential harm that exists
with a computerized system that demands attention. Clearly,
and in some cases, breach of confidentiality may, in fact,
be easier to achieve with a manual record. One exaample is
that hospital personnel could access a record more quickly
by having the patient name and room number, going to the
floor and getting the chart rather than getting a password
and having to identify the patient’s hospital number before
accessing the information via a computer.

The key appears to be in the educational process in
the training of employees, including physicians, to
the system and having physician cooperation. This was cited
learlier as a means to ensure confidentiality, albeit
indirectly, since the educating of ethics and citizen
rights should be incorporated in all training programs.
Conversely, the knowledge of the system, how to get in and
what information to obtain, may open the door to further
abuse. What is needed is an appropriate software package
with built-in security measures for this very reason. A

means should exist to 'track’ what information is being

78
accessed, by who, who is logging into the system and at
what time. This would facilitate the ensurance of patient
confidentiality by tracking the amount and type of
information flow. This appears particularly critical given
the study’s finding of research and statistical studies as
one of the most frequently cited uses of patient data.
Given that the means of monitoring information usage for
research purposes is not clearly defined or accomodated via
a software package requires not only further study, as
suggested, but indicates the ease of violation in the
breaching of confidentiality given a computerized system.
The best example of this, as taken from this study, is the
design of the CPHA system where the Data General equipment
is not password protected and as long as hospitals have the
same equipment, software package and the ARDOS operating
system, an individual’s password in Michigan gets them into
a system in Colorado. Admittedly, this computerized system
does not ensure patient confidentiality.

This study takes root in today’s social climate. The
United States is in an Information Age, with
computerization meeting the need to manage large quantities
of data. Two prevalent public health issues are AIDS and
drug usage with society being challenged as to the best
means to handle these problems. Against this backdrop are
civil rights liberties that are intrinsic to American

values. This study becomes a first step, for this writer,

79
in recognizing the need to balance the issues as they

converge in the 1980’s.

CONCLUDING COMMENTS

As American society reorganizes and redefines its
health care system, increased use of computer technology
is inevitable.18 Citizen rights can not be a casuality of
technological advancement and American tradition demands
such rights to be served as more than an accidental
beneficiary of computer security practices or handled on an
ad-hoc basis. Critical to such insurance of confidentiality
are adequate training programs with physician cooperation
and support in this endeavor, as the findings suggest.
Given that a more comprehensive system (ie: interfacing and
networking with more departments) is cited most frequently
as a priority supports all the more the need to insure
confidentiality practices since with such a system the
potential exists for more information to be disseminated
throughout more hospital departments. Ethics committees
would provide impartial, independent review of such
departments’ practices and policies thereby safeguarding
confidentiality. The initiatives of several departments and
organizations are required to promote the continuity of
citizen rights with patient representatives upholding and

serving these rights.

80
Continued research, concurrent with careful planning
and evaluation at the private and public levels, offers the
best opportunity to insure confidentiality with the
computerization of medical records. Only then will
traditional laws and organizational policies keep pace with
the automation of the medical record thereby insuring

appropriate usage and maintenance of confidentiality.

 

81
FOOTNOTES
1

tiE'EEEFetZPg—r'S‘XEGiSSPy'EBmfiItEES 33 ZEESEEEZE Data

Systems, US Department of Health, Education and Welfare,
1973, p. 19.

2
Brandeis, Jan F. Health Informatics: The Canadian

Experience. The Canadian Medical Association, Ottawa-North

Holland Publishing Company, New York, 1976, p. 45.
3

Rights. US Department of Commerce, Washington, D.C., 1976,

Comber, Edward, "Management of Confidential Information,"
Computers and Security, Alps Press, New Jersey, 1978, p.

Rights. US Department of Commerce, Washington, D.C., 1976,

Ibid., p. 296.

Ibid., p. 296.

Ibid., p. 299.

Ibid., p. 297.
10

Publishers, New York, 1979, p. 325.

11
Ibid., p. 325.

12
Patient Bill of Rights. American Hospital Association,

82

13

Westin. Alan- Qenpntenei deelth Reeende end Qitieen
Rigdiai US Department of Commerce, Washington, D.C., 1976.
p. 297

14
Ibid., p.300.

15
Ibid., p.300.

16
Waters, Kathleen and Gretchen Murphy. Madigai Ragagda ia
Health Information. Aspen Systems Corporation, Germantown,

Maryland, 1979, p. 264.

17

Westin. Alan- Qenpntenei deelth Reeende end Qitieen
Righta. US Department of Commerce, Washinton, D.C., 1976,
p. 308.

18
Ibid., p. 308.

APPENDICES

,‘fi-l-fi

Appendix 1:

Users of Health Information

Users and Uses of the Medical Record

Uses of Health Information

 

Health Care Providers. Institutional and
Individual

Maintain communication among health care providers during the current episode of illness
Facilitate continuity of care for patients and assessment of the efficacy Of the care given
Assure appropriate reimbursement

Assist medical and allied health students in relating theory to medical practice

Evaluate quality of patient care °

Assess use of facilities. equipment. services. personnel. and financial resources
Document compliance with standards for accreditation and government regulations

Conduct research aimed at the improvement of treatment. assessment of disease detection methods.
assessment of the effectiveness of medication and other treatments through study of appropriate cases

Plan for future health care delivery systems to meet patient and communiy needs

 

Payers for Services. Private insurance Plans.
Govemment Insurance Plans and Their Review

Organisations _

O

Substantiate patient claims for payment of health care services

Substantiate the data on which reimbursement is based

Monitor the appropriateness of care and services rendered to the insured

Assess the cost of health care services to the insured 'e

 

Social Users: Public Health Agencies. Medical
and Social Researchers. Rehabilitation. Social

Monitor disease epidemiology
Investigate disease patterns. sheets of disease on functions of daily living. effects of. treatments

 

Welfare and Home Care Programs .
Assess need for specific types of health care programs and services
Lump program plans for health care programs and services
Employers Assess job related injuries and occupational hazards

Federal. State. and Local Government Agencies

Document extent of disability

Determine appropriate allocation of government resources for schools. health care facilities. educa-
tional institutions

DeveIOp plans for health care programs and services

 

Judicial Process
Media: Press. Radio and TV

Patients

Accrediting. Licensing. and Certifying Agencies

Source:

 

Adjudicate civil and criminal matters through use of the medical record as evidence
Aid the judicial process for involuntary admission of the mentally ill

Report health hazards. diseases affecting the public health and newsworthy events. and developments
in medical research ‘

Assist in understanding their health care

Aid continuity of care for future treatment

Assess individual fulfillment of criteria for professional licensing by a state government agency
Ascertain competence of practitioners

Determine compliance with criteria for hospital—based educational programs

Document compliance with standards for institutional accreditation

1982 by the American Medical Record Assoication. A

position statement on Eeniideneielit! of Eetient Eeeitn

Information.

83

Appendix 2:Institutional Policies for the Disclosure of
Medical Record Information

Source: 1979 by the American Hospital Association, 840 Lake
Shore Drive, Chicago, Illinois, 60611.

APPENDIX 2 < ~

 

AMERICAN t
HOSPITAL
Assocumon

INSTITUTIONAL POLICIES FOR DISCLOSURE OF
MEDICAL RECORD INFORMATION

Thar guidelines were developed by the American Hospital Association '3 Advisory Panel on Privacy and
C onfldcntialit y of Hospital Medical Record: to promote and preserve the confldcntialit y of hospital
medical record: and to establish principle: and recommendation: for appropriate access to them. The
principle: established in this document supersede those on the use and release of hospital medical record
information as contained in the 1972 book published by the Association. Hospital Medical Records:
Guidelines for Their Use and the Release of Medical Information (Al-IA no. IZSOM). There

guideline: were approved by the A HA Board of Trurtcc: in November I 978. Use of these guideline: is
suggested in conjunction with the Association's Statement on Preservation of Medical Records in
Health Care Institutions ($003). The Association is also preparing a companion handbook on medical
record procedure: to correspond with the principic: in these guidelines and to replace the l 972 book.

Introduction

Changes in the social and economic environment. accom-
panied by rapid growth in record-keeping capabiiitics. have
produced an intensive need and demand for more kinds of and
more detailed patient and patient-care information. Never

before have hospitals had to keep so much information to _

make possible the completion of daily transactions involving
patient care and delivery of sen-ices. Never before. have
hospital medical records been subjcczcd to so many demands
for their use and-disclosure of contents. ‘

The informational upsurge is largely the result of:

0 Increasing complexity of medical care associated with the
growth in size and variety of professional disciplines in-
volved in the, delivery of health care services.

a Wide-scale use of computers in marshaling information.
processing information exchange. and creating data banks.

0 Increasing mobility of the population. with the consequent
increase in the volume of requcsu for exchange of medical
information.

0 Expanding informational needs of governmental agencies
for planning. administration. evaluation of government
programs. and policy-making purposes.

0 Progressive growth in the number of third parties‘ concerned
with the patient and his medical record. Many of these third
parties are seeking information for proposed uses. such as
payment for patient care. that are quite different from the
primary purpose for which it was collected.

0 Increased government access to patient-identifiable records
and increased reporting of personal information to the
government. ‘

0 Increased incidence of health-related legal actions and

proceedings.

 

‘A party other than the patient. the patient's personal representative. the physi-
cian. or the hospital.

81:-

Q POtcntiaI misuse of the authorization for disclosure of
medical record information.

A searching examination .by the American HJscital Associa-
tion on how best to use and control hospital medical records
brought forth contrasting ind sometimes: conflicunglcicws on
how to ensure privacy rights while arthrsairn'c lime ,rc'cbgnizi“
ing the legitimate interests of third parties. Of concern to the
Association is the prcl. ailing tcnccnqgoffi-ifmmation seekers
to disregard or be unaware of the hospital's oingation to
rcspccsthc right of patients ioeerscinal privacy and to treat
records pertaining to their care as cOnfidcntiaI.

As the first step in, striking‘ a proper balance between the per-
sonaI privacy rights of patients and the inl's'lrmatlonal needs of
hospitals and society in gc’ncr'cI. the American Hospital
Association believes that it is essential fer hospitals to have a
chlodcflncd policy on the use and disclosure of medical infor-
mation. This policy should limit disclosures to essential pur-
poses. rcstrict information disclosure to that necessary to ac-
complish those essential purposes. promote the use of an
authorization for disclosure of medical records. and recognize
the limitations of the medical record in performing the many
services expected of it. However. provision should be made for
those instances when nothing less than a full disclosure of the
medical record will suffice.

These guidelines have been prepared to assist hospitals in
developing policy manuals on the disclosure of medical record
information. Following the concepts of policy formation. the
guidelines define areas in which decisions are made and es-
tablish policies to cover the areas deemed important. Princi-
pIcs established for internal use differ from those established
for external use. Recognition also is given to the exceptional
situations that may require special handling.

Characteristics of the medical record

The development of policies on disclosure of medical record
content must begin with a set of basic principles. These basic
principles relate to the characteristics of the medical record:

a.
a‘ '

85

purpose. content and format. disclosure. ownership. confiden-
tiality. and accessibility of the medical record.

Purpose ‘_

The primary purpose of the medical record is to documer .t the
course of the patient‘ s illness and treatment during all periods
'of care. whet her as an inpatient or outpatient. The record is
important in medical prac: ice. It serves as an instrument for
communication among physicians and Other professionals
contributing to the patient's care and as a basis for planning
and evaluating that care.

The secondary purposes of the medical record are:

0 To serve as a source for substantiation of the patient care
services and treatment provided.

0 To provide clinical data of interest to researchers and con-
tinuing education programs.

0. To meet and support legal and quasi-legal obligations im-
. posed on the hospital and the physician.

Content and format

The medical record is used by practitioners in the management
of patient care. Because of this use. the objectives of effective
patient care should serve as the basis for determining content.
methods of organizing clinical information. desired manner
and style of recording. adequacy and timeliness of entries. and
justification for exclusion or inclusion at information.

Ownership-

Records of the hospital. including medical records maintained
for the benefit of the patient. the physician. and the hospital.
are regarded as the property of the hospital. Legal counsel
shbuld be consul ted as to applications of local laws.

Disclosure .

Subject to applicable legal provisions. ihe hospital may restrict
removal of medical records from its files or from its pre...ises.
determine who may have access to their contents. and define
the information that may be disclosed. In fact. state laws or
regulations. or the need to preserve the admissibility of records
as evider .ce-in judicial proceedings. may manna-2e that records
be removed only for hospital or courtroom purposes.

C onfidentialit y

The patient has the right to expect that records pertaining to
his care will be treated as confidential. and the hospital has the
obligation to safeguard his records against unauthorized dis-
closure.

A ccessibility

Medical records should be used within the hospital only by
authorized recipients on a need-to-know basis. Responsibility
for disclosure of medical record information by the hospital.
with or without the authorization of the patient to whom it
pertains. should be delegated to hospital personnel who un-
derstand the characteristics of the medical record and
recognize the occasional situations that require the advice of a
medical staff member or the hospital attorney.

Policies for internal disclosure

The hospital shall provide for the security of the medical

record and establish internal policies to provide for their
proper use as needed to carry out functions within the
hospital. Access to the medical record without the written con-
seat of the patient depends on: ‘

0 The authority and responsibility of the hospital or medical
staff member or duly appointed committee or panel re-
quesring access.

0 The reason for the request.

0 The kind of information required.

Policies for internal disclosure of medical record information
should be established for various functions within the hospital
as described in the following paragraphs.

Governing board and chief executive officer

Legal precedents recognize the right of access by the governing
board of the nospitai in order to ensure quality of patient care.
All hospital policies on the use of the. 1'. -cical record and on
disc .osure of medi al record content ‘shocld be prepared in
consultation with the hospital attorney and are subject to
review by-the governing board of the hospital.

The chief executive officer has access to all re
whenever necessary to carry 'out his management searpimsibil-
ity. Except when laws or regulations dictate otherwise. the
chief CXC”"U\C off": 2:: also ha 5 the responai'ctiity torfiaal-deci-
sions on what m..d iccl rec crd disclosures may be made'and-the
circumsta. .223 under which disc .osures may be made.

cords-ofpatients

Hospital security
It is the responsibility of the hospital to establish and-imple-
rn-L-nt security measures that reasonably satcguard N-“b the
.edl cal record audits im'crrn- :clrt’al content. in: thermhard
copy. on f lm; or in computerizec form. againsr loss. deface-
ment. tampering. unauthorized disclosure.‘ and use by- on-
~authorized personsI'AIl officers and employees or -'..‘re hovpital
must be made aware of-their-‘ceponsicalty in mainvhniug the
confidentiality of medics. record information and af" ... a dis-
ciplinary aetions that may be taken for unauthorized dis-
closures of patient-identifiable information. ~

Patient care

Use of a patient's previous medical record. both inpatient and
outpatient. by physicians and other health care professionals
involved in the care of that patient at the institution maintain-
ing the record does not require the patient's signed authoriza-
tion because consent to such use is implied. Disclosure of
medical information in the event of direct referral or transfer
of the patient to another medical care provider does not re
quire the patient' 3 signed authorization. A record should be
kept of the information disclosed. -

Qualitv evaluation

Because of its responsibility for determining whether the qual-
ity of care provided to all patients is consistent with standards
as provided for in the medical staff bylaws and in the requi-
sites for hospital accreditation. the hospital can use medical
record information for quality evaluation without the express
authorization of the individual patient to whom it pertains.
However. all individual patient identification should be ex-
cluded from the routine report of such findings and recom-

86

mendations. When circumstances dictate otherwise. a coded
method of identification may be appropriate for internal use.

Education programs

The hospital should establish rules for the use of medical
records in hospital-approved education programs for medical
and health care professions and should disseminate the rules to
the appropriate program directors and instructors. who also
must share the responsibility for protecting the confidentiality
of the medical records and ensuring the availability of the
records for patient care purposes.

Research

The rules of the hospital shall define the extent to which physi-
cians and other health care professional Staff in good standing
are privileged to use the medical records for bona fide study
and research and shall define circumstances that require
patient authorization for such use. Anyone using the medical
records for bona fide study and research must also share the
responsibility-for protecting the confidentiality of the medical
records and enSuring the availability of the records for patient
care-purposes.

Health data systgms and data registries’

The hospital. as a provider and user of data resulting from its
maintenance gland/or participation in a health data system.
shall ensure that reasonable care is taken to:

O Safeguard the privacy rights of persons identified therein.
Ir-Collect and store relevant information.

0 Establish-'standards for accuracy.

_ timeliness. and com-
pleteness of data input. '

‘0 Obtain am} maintain security'of conl'tder .tial data. -

0 Control: unauthorized disclosure in patient-identifiable.
physician-identifiable. orhospital-identifiable form.

0 Validate statistical data.

‘l Closely monitOrt-lie data sy stern for its continuing-adherence
to previously agreed upon policies and procedures.

Hospital affairs

Access to the medical record without patient authorization
should be provided only on a need-locknow basis in the
management of hospital affairs. including that necessary for
performing internal administrative tasks. conducting quality
assurance programs. receiving legal counsel. planning health
services. and surveying hospital-approved programs for ac-
creditation compliance. Staff access to medical records shall be
commensurate with a person's responsibility and authority for
conducting hospital business. Disclosures of medical record
content shall be ,made only by those suitably trained or
qualified to do so.

Policies for external disclosure

The hospital Bhall establish policies for the disclosure of
medical record information to meet the various controls and
requests that arise from outside the hospital. Elements to be

 

’For further information. see the AHA Statement on Health Care Data. AHA
catalog no. 5032.

considered in policy formulation include:
0 Types of requests.

0 Kind of information requested.

0 Persons. agencies. or organizations authorized to receive
information.

0 Permission needed for disclosure.

0 Conformance to laws. regulations. and other measures in the
public interest.

0 Esmbllshment of reasonable charges for furnishing capies.

Provision should be made for handling exceptional requests
that result in decisions that may constitute additional policies
or important modifications of existing policies.

Policies for external disclosure should be established to cover
all events usually faced by the hospital as described below.

Authorisation for disclosure

The hospital shall respect each patient 5 expectation that
records pertaining to his care will be treated as confidential.
Therefore. n’o hospital should disclose. or be required to dis-
close. medical record information in patient-identifiable form
to a third party without the patient's authorization. unless
such disclosure is:

0 Pursuant to law or statutory regulations requiring the hos-
pital to report certain information.

0 In accordance with compelling circumstances affecting a
person's health or safety.

0 Permitted under certain circumstances by the hospital in the
conduct of biomedical. epidemiologic. or health services
research projects.

0 Limited to name. date of admission. and general condition.
except in those instances when the patient or his authorized
representative requests that even this limited information

A not be released or when laws or regulations (for example.
alcohol and drug abuse treatment) forbid the disclosure of
this information.

Patient authorization

Written authorizations are a good practice and may be man-
dated under some regulatory requirements: for example. the
Federal Drug and Alcohol Abuse Act.

One of the purposes of a well-drawn authorization for dis-
closure of medical record information is to indicate to the
patient. or person acting on his behalf. what subject matter is
being authorized to be disclosed. the person or Organization
that will receive the information. and any applicable time limit
(see pages 7 and 8).

Disclosure limits

The hospital has a responsibility to limit the disclosure of in-
formation to only that which is stated on the authorization or
required by law and to limit disclosures made without the
patient‘s authorization to only that information permitted or
required by law to accomplish the purpose for which the dis-
closure is made. Whenever disclosure is made pursuant to the

87

written consent of a patient involved in a drug Or alcohol
abuse program or treatment function. such disclosure must be
accompanied by the followi g statement: “This information
has been disclosed to you frog: records whose confidentiality is
protected by Federal law. Federal regulations prohibit you
from making any further redisclosure of it without the specific
written consent of the person to whom it pertains."

Record of authorization

The hospital should maintain either the original or copies of
the patient's disclosure authorization. which should be made
available for examination by the patient.

Careful consideration should be given to keeping a notation of
all disclosures to third parties.

Other health care providers
The hospital shall not honor a request from another hospital. a
nonstaff physician. or other health care provider for patient-
identifiable medical record information unless the request .is
accompanied by that“patientis authorization for disclosure. ex-
cept under certain conditions-warranting immediate disclosure
to a properly-identified medical care provider or public health
officer. Examples are: (ll-a showing of compelling circum-
stances affectingthe health or safety of a person or (2) when
needed in connection with a direct referral or transfer of the
patient from the hospital to another medical care provider.

Third-parry contractors

The hospital shall not disclose. without the patient's authori-
zation. information from the patient‘s medical record purlsu-
ant to the hospital's agreement with a government agency or
Other third-party payer for payment of hospital service charges
to authorized beneficiaries-or clients of such a program or
plan. unless disclosure is:

.0 Granted by the hospital on behalf of a patient to determine
benefits entitlement when- the patient is unable to com-
municate an authorization for disclosure.

0 In accordance with provisions of a particular hospital/third-
pcrty agreement for inspection of certain portions of a
.medical record—in the performance of claims processing or

- financial audit.

Insurance carriers

The hospital shall not disclose to an insurance company or in-
surance plan any patient-identifiable medical record informa-
tion maintained by the hospital unless the request is accom-
panied by the patient‘s authorization for disclosure or by an
authorization for disclosure of information necessary to pro-
cess the insurance claim(s).

Hospital accreditation and licensure surveys

The hospital shall acknowledge the requisites of hospital ac-
creditation and state licensure bodies to review medical
records maintained by the hospital only to the extent required
or expressly authorized in the performance of their duties to
ensure compliances with approved standards or statutory
regulations for medical records. provided the reports of such
surveys do not directly or indirectly identify any individual
patient.

Government programs
The hospital shall recognize requests for access to or reports of

patient-identifiable medical record information for evaluation.
audit. or certification purposes by government agencies pur-
suant to the administration of a government program only to
the extent expressly authorized in applicable statutes or regula-
tions. or if the hospital receives an administrative summons ex-
pressly authorized in applicable statutes and issued by ad-
ministrative or executive authority of government or a judicial
subpoena or court order. The summons should identify par-
ticular record(s) and/or items of information to be made avail-
able to the agency. '

Evidence and investigation

The hospital should disclose to attorneys. tribunals. members
of the court. or government investigation and law enforcement
agencies medical record information in patient-identifiable
form only if disclosure is authorized by the patient. unless dis-
closure is compelled by judicial subpoena. court order. prop-
erly issued and authorized administrative summons. or as
otherwise mandated by law.

Biomedical. epidemiologic. or health services research

The hospital‘s chief executive officer shall determine whether
or not to permit medical records maintained by the hospital to
be used by a third party for purposes of conducting biomedio
cal. epidemiologic. health services. or related research and .
whether or not the patient's authorization is required in ac-
cordance with established hospital policy.

The following determinants should be considered in making
the decision:

0 The importance of the project's purpose outweighs any
nominal risk to individual privacy rights.

0 The proposed methodology does not violate any limitations
under which the medical record information was-collected.

O The safeguards are adequate to protect the confidentiality
and integrity of the medical record and information therein.

0 The further use or redisclosure of any medical record infor-
mation in patient-identifiable. physician-identifiable. or hos-
pital-identil'table form requires the written consent of the
chief executive officer of the hospital. who shall exercise due
regard for the rights of others affected.

0 The medical records of the hospital are a suitable source of
information for the purpose for which they are to be used.

0 The third party makes appropriate commitments for safe-
guarding the patient's privacy. including. in some instances.
an agreement to refrain from contacting the patient or
others.

Public health laws

The hospital should disclose. without patient authorization.
medical record information in patient-identifiable form pur-
suant to the provisions of state vital statistics laws. which man-
date registration of births. deaths. and fetal deaths. and of
other public health laws that compel reporting of certain
epidemiologic conditions.

School referrals
The hospital should not disclose to administration personnel.
teachers. or nurses in the local school system the results of

\
~

88

diagnostic tests on students referred to the hospital by the
school system unless such disclosure is authorized by the stu-
dent's parent(s) or guardian or. if the student is an adult or
emancipated minor. by the student.

Employer requests

The hospital should not disclose to an employer any
information on an employee who is the subjeCt of a medical
record maintained by the hospital without the employee's
authorization for disclosure. unless such disclosure is pursuant
to any state or local statute(s) providing specific authority for
such disclosure.

Policies for disclosure to patients

The American Hospital Association‘s statement entitled A
Patient's Bill of Rights‘ states: “The patient has the right to
obtain from his physician complete current information con-
ceming his diagnosis. treatment. and prognosis in terms the
patient can be reasonably expected to understand. When it is
not medically advisable to give such information to the
patient. the information should be made available to an ap-
propriate person in his behalf."

In addition to information available from the physician. the
law (statutory or judicial) of most states recognizes a
reasonable right of access to medical record information by
the patient or his nominees. The patient’s right of access in no

. way abrogat’cs the hospital's property. rights in its record-and
its. right to establishmsonable procedures for access to the

-‘patient's record: .‘T he attending. physician should be notified of

*the patient'-s request for access to the medical record. Records
containing information that might be detrimental to the
physical and ,’ or mental health of the patient. as determined by
-the attending physician.- should be released in a form that
minimizes any adverse effect on the-patient.

'When it is known that patient access to medical record infor-
mation may be medically contraindicated. the hOspital may re-
quire that a physician or his designee inspect the record and
communicate the appropriate information.

Fairness protection

The hospital's record-keeping relationship with the patient on
whom it maintains a medical record is that of fairness and
protection of confidential information.

0 A person has the right to verify that the hospital has created
and is maintaining a medical record pertaining to care or
services provided to the person by the hospital.

0 A patient has the right to find out that a disclosure of his
medical record has been made and to whom it has been
made. if such information is available.

0 A patient has the right to expect the hospital to exercise
reasonable care in protecting the confidentiality of the
medical records it maintains.

0 Unless access is believed by the attending physician to be
medically contraindicated. the patient may look at the
record of medical care provided. may request a copy upon

 

‘American Hospital Association. A Patient's Bill of Rights. AHA catalog no.
SM. Chicago. I975.

payment of reasonable charges for the service. and may re-
quest correction or amendment of information.

0 A patient's personal representative(s) or duly authorized
nominee(s). upon good cause shown by such person(s). may
be granted reasonable access to information contained
within the patient's medical record.

Development of policy and procedure

The hospital should develop a policy for internal use that sets
forth (I) a person's ability to verify whether or not the hospital
maintains a medical record of care and services provided to
that person and (2) the scope of a patient‘s right of reasonable
access to the record of medical care provided. The policy
should encompass existing centralized and departmentalized
systems of medical records. Development of the policy and the
related procedures should take into consideration:

0 The responsibility of the hospital to provide reasonable ad-
ministrative. technical. and physical safeguards to ensure
that records are disclosed only as expressly specified in ap-
plicable laws and regulations. in the patient's signed
authorization. and in the hospital's written policies and
procedures. A

O The identification of record systems within the hospital.
such as records created and kept on inpatientsaoetpatients.
emergency service patients. home-care patients. and private

, outpatients referred for diagnostic or‘th‘erapeutic services.

0 The delineation of hospital policy and any regulatory re-
quirements on preservation. retention. and retirement
schedules for patient-identifiable records. including those
collected and maintained within the various departments of
the hospital.

0 Measures to provide evidence of all disclosures of medical
record information. Other than those made during routine
use within the hospital. and the retention of such evidence
with the record from which the information was disclosed.

O The notification of the attending or responsible physician(s)
When a patient requests access to his medical record.

0 The designation of a committee or a hospital staff member
and a medical staff member who are granted authority and
responsibility for implementing and overseeing hOSpital
policy and procedures on patient access to medical records
and reviewing judgment thereunder.

O The steps involved in receiving and considering the patient's
request for a correction of or an amendment to his medical
record. including notification to the attending or responsible
physician of such request and notification to the patient as
to the acceptance or denial of the request.

0 The establishment of a mechanism. which might consist of a
committee or panel. to review denial of a patient‘s request to
correct or amend his record.

0 The establishment of special procedures to handle requests
by the patient or the patient‘s family for access to medical
records when direct access apparently could be harmful to
the patient.

89

0 The identification of a miner’s right to access to the medical
record as may be permitted under general state law or state
law permitting a minor to eelt on his own behalf. without
the knowledge or consent his parents. treatment for cer-
tain conditions. such as venereal disease. alcohol or drug
abuse. and pregnancy. and for family planning and abortion
services.

However. when a claim against the hospital or its medical staff
members is threatened or pending. or after suit has actually
been filed. requests by patients or their attorneys or other
representatives for access to the patient's medical records
should be brought to the hospital attorney‘s attention im-
mediately. The attorney may then advise whether. when. how,
and under what circumstances such access should be granted
or copies furnished to the requesters.

lf state law permits a minor to obtain certain treatment
without the knowledge or consent of his parents. there may be
instances in which only the minor may have access to the
medical record. or the minor must give consent for his
parent(s) or guardian to obtain the information. Hospitals will
need legal advice on any provisions related to minors in ex-
isting laws. such as in laws concerned with drug or alcohol
abuse. venereal disease. certain other contagious diseases.
pregnancy. family planning. and abortion.

Suggested practices for notification and access _

The relationship of the hospital‘s medical record-keeping prac-
tices to the patient's stated interest in the medical record main-
tained by the hospital is that of fairness in the procedures
developed to:

O Confirni to a person. upon request. whether or not a record
of medical care provided is currently kept by the hospital.

0 Allow a patient to find out. if the information is available.
whether or not a patient-identifiable disclosure has been
made to a third party and. if so. to whom it was disclosed.

0 Arrange for a patient to see an’d/or obtain a copy of the
record of medical care provided. or portions thereof. and
allow the patient. if so desired. to be accompanied by a per-
son chosen by the patient.

. Arrange for access to the medical record by a qualified
medical care professional and/or other responsible person
so designated by the patient when direct access by the
patient is deemed medically contraindicated by the attending
physician.

0 Consider a patient’s request for correction or amendment

, of the medical record and. if not granted. allow a statement

of the patient's disagreement to be filed in the record of
medical care provided.

The hospital should designate a specific office to which all in-
quiries related to a person's interest in the record of medical
care provided. including those received by mail. telephone. or
delivered in person. should be referred.

Hospital procedures should be developed to inform persons
requesting information about a medical record or access to a
record that such requests should be free from ambiguity or un~

certainty as to identification of the patient. Such requests for
information should:

0 Be made in writing. signed. and mailed or delivered to the
designated office.

0 Describe the type(s) or scope of records being sought and the
manner of response desired by the inquirer.

When identification of a person or the person's designee is un-
certain. the inquirer may be asked to give further or more cer-
tain identification. such as date of birth. known or approx-
imate dates of visits or admissions to the hospital. and any
known hospital identification numbers. such as medical record
or account number. Persons who mail. deliver. or complete in
person a written request that contains insufficient identifying
or other information should be advised of the additional
requirements.

Responses to all written requests pertaining to notification or
access should be made promptly. if possible within l0 business
days following their receipt. if a full response cannot be made
within that time. an acknowledgement should be sent to in-
dicate that a response will be forthcoming.

If there is no evtdence of an existing record or if the record in
question has been retired. the inquirer should be so advised.

lf identification is made and the record is available. the at-
tending or responsible physician(s) should be notified of the
request.

Form letters may be prepared to:

0 Confirm whether the hospital maintains. subject to record'

retirement policies. a medical record on the person who is
the subject of the inquiry. which may indicate inpatient. out-
patient. emergency service care. utilization of only depart-
mental services. or other type of record.

0 Act as a cover letter accompanying the transmission of re-
quested information to the patient or patient's authorized
representative. -

0 Send notices of fees. to be remitted in advance. to cover the
routine costs for preparing copies.

0 Notify when and where the records will be available for per-
sonal inspection.

Procedures for personal access

If a patient elects to see and /or obtain a copy of the record. the
attending or responsible physician(s) should be notified and
the patient should be informed that:

0 The record will be available at a certain place on specified
days and during given hours.

0 The patient may be required to furnish adequate self-
identification.

0 If the patient chooses to have another person present during
the review. the hospital may require the patient to sign a
statement to that effect.

To ensure the integrity of a medical record during such personal

\
O .

90

review. a designated hospital employee should be present at all
times. To the extent feasible or desirable. a physician or qualified
employee may be present to assist the patient in reading the entries
in the record. 1.

Requests for correction or amendment

A patient's request for correction of or amendment to the
medical record should be submitted in writing and should
specify the entry or entries in dispute. With the exception of re-
quests for correction of such items as time of admission.
birthdate. spelling of name. and other such admission data
that can be handled by qualified employees. the attending or
Other responsible physician(s) should be notified of requests
received for corrections or amendments. The hospital and at-
tending physician(s) will decide whether or not the correction
or amendment is to be made.

If the decision is made to correct or amend the record. the
patient should be so advised. Any correction or amendment
should not obliterate the material corrected.

If the request for correction or amendment is not granted. the
patient should be informed that a statement of the patient‘s
disagreement can be filed with the hospital and that the dis-
puted entries in his medical record will be appropriately an-
notated to reflect this disagreement. Any further disclosure of
the medical record Will include this statement of disagreement
and the annotations. '

Model authorization for disclosure.

In determining the effectiveness of an authorization for
medical record disclosure. the following elements would be
considered necessary under the laws of most states:

0 Name or other sufficient designation of the hospital or other
custodian of the medical record to which the authorization is
addressed.

0 Names of each person. firm. corporation. or public body to

which information or copies of records may be released by
the custodian of medical records.

0 Adequate designation of information to be disclosed. subject
to restrictions by the patient to disclosure of a specific
medical condition. injury. time period. and/or any Other
type of specified information.

0 Signature of the patient on whom the medical record is
maintained. or of a person lawfully authorized to act in the
patient's behalf. and the date the authorization form was
signed.

0 Specified expiration date. if consistent with purpose of disc
closure. For example. the patient may wish the authoriza-
tion to be for a reasonable specified time period. except
when an authorization is presented in connection with a life
or noncancelable or guaranteed renewable health insurance
policy or with payment claims for health services provided.
In the absence of a contract. an authorization may be
revoked by the consenter at any time. '

0 Agreement by the recipient not to further disclose such in-
formation. or make copies of it. unless further disclosure is
expressly permitted in the original authorization or is by
necessary implication inherent ingthe purposes .of the
original consent or authorization. '

O Prohibition'of proposed new use of inforination without
additional written consent.

Using the desired elements of an authorization for disclosure
of medical record information. authorization forms can be
developed to provide a reasonable assurance that a patient
may authorize disclosure only .to the extent desired. A
suggested form for this purpose is shown on page 8.

Other and more specialized forms may be devised for-special
purposes. such as release of information to facilitate payment
of hospital services provided. An example of such a form is
shown below.

EXAMPLE OF AUTHORIZATION FOR DISCLOSURE OF INFORMATION FOR HOSPITAL PAYMENT

Patient's name:

 

Re: Admission or hospital services commencing

 

DA TE

The undersigned hereby authorizes

 

to release to

 

NAME OF HEALTH CARE PROVIDER

 

 

INSLRANCE CARRIERISI OR NAME OF PARTY THAT IS OR MAY BE LIABLE FOR ALL 0R PART OF THE HOSPITAL CHARGES

 

only such diagnostic and therapeutic information (including any treatment for alcohol or drug abuse) as may be necessary. to
determine benefits entitlement and to process payment claims for health care services provided to the above named patient.

This authorization shall be valid only for the period of time necessary to actually process payment claims pertaining to the patient

but in any case shall cease to be valid

Signature:

years from this date.

Date:

 

 

IE SIGNED IY PERSONAL REPRESENTATIVE. STATE RELATIONSHIP AND AUTHORITY TO DO SO.

ANY DISCLOSURE OF MEDICAL RECORD INFORMATION BY THE RECIPIENT(S) IS PROHIBITED
EXCEPT WHEN IMPLlClT IN THE PURPOSES OF THIS DISCLOSURE

Appendix 3A: H.R. 668

Source: Reprinted, with permission, from Medical Records in

Egglth Lgfggyggigg, 1979, Aspen Systems Corporation.

APPENDIX 3A

Bill 668

H.R.

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91

Appendix 33: H.R. 2979

Source: Reprinted, with pernission, from Medical Records in

ggg;gg lgfgggggigg; 1979, Aspen Systems Corporation.

APPEND IX BB

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PBOMULGATION OP REGULATIONS
SEC. 302. The Secretary shall first establish final regu-
lations to carry out the amendments made by this Act not
‘ later than the first day of the second month that begins
before the effective date of such amendments (as specified

under section 301).

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Appendix 30: S. 503

Source: Reprinted, with permission, from Medical Records in

flggltg lgfiggggtiggL 1979, Aspen Systems Corporation.

APPENDIX BC

S. Bill 503

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Appendix 4: American Medical Association: Confidentiality
and Computers

Source: 1984 by the American Medical Association, 535 North
Dearborn Street, Chicago, Illinois, 60601. ggggggg Qpigiggg
of the Judicial Council of the American Medical

5.07

APPENDIX ‘5

American Medical Association: Confidentiality

and Computers

CONFIDENTIALITY: COMPUTERS. The utmost effort and care
must be taken to protect the confidentiality of all medical records.
This ethical principle applies to computerized medical records as
it applies to any other medical records.

The confidentiality of physician-patient communications is
desirable to assure free and open disclosure by the patient to the
physician of all information needed to establish a proper diag-
nosis and attain the most desirable clinical outcome possible.
Protecting the confidentiality of the personal and medical infor-
mation in such medical records is also necessary to prevent
humiliation, embarassment, or discomfort of patients. At the
same time, patients may have legitimate desires to have medical
information concerning their care and treatment forwarded to
others. -

Both the protection of confidentiality and the appropriate re-
lease of information in records is the rightful expectation of the
patient. A physician should respect the patient's expectations of '
confidentiality concerning medical records that involve the pa-
tient’s care and treatment. but the physician should also respect
the patient's authorization to provide information from the medi-
cal record to those “whom the patient authorizes to inspect all or
partof it for-legitimate purposes.

Computer technology permits the accumulation. storage, and
analysis of an unlimited quantum of medical information. The
possibility of access to information is greater with a computerized
data system than with information stored in the traditional writ-
ten form in a physician’s office. Accordingly. the guidelines
below are offered to assist physicians and computer service or-
ganizations in maintaining the confidentiality of information in
medical records when that information is stored in computerized
data bases. It should be recognized that specific procedures
adapted from application of these concepts may vary depending
upon the nature of the organization processing the data as well as
the appropriate and authorized use of the stored data.

Guidelines on a computerized data base:

(1) Confidential medical information entered into the comput-
erized data base should be verified as to authenticity of source.
(2) The patient and physician should be advised about the exist-

128

129

ence of computerized data bases in which medical informa-
tion concerning the patient is stored. Such information
should be communicated to the physician and patient prior to
the physician's release of the medical information. All indi-
viduals and organizations with some form of access to the
computerized data bank. and the level of access permitted,
should be specifically identified in advance.

(3) The physician and patient should be notified of the distribu-
tion of all reports reflecting identifiable patient data prior to
distribution of the reports by the computer facility. There
should be approval by the physician and patient prior to the
release of patient-identifiable clinical and administrative data
to individuals or organizations external to the medical care
environment, and such information should notbe released
without the express permission of the physician and the pa-
tient.

(4) The dissemination of confidential medical data should be lim-
ited to only those individuals or agencies with a bona fide use
for the data. Release of confidential medicai infomation—fwm
the data base should be confined to the specific purpose‘for
which the information is requested and limited to the specific
time frame requested. Allsuch organizationsor individuals
should be advised that authorized release of data to them does
not authorize their further release of the data to additional
individuals or organizations.

(5) Procedures for adding to or changing data on the comput-
erized data base should indicate individuals authorized to
make changes. time periods in which changes take place. and
those individuals who will be informed about changes in the
data from the medical records.

(6) Procedures for purging the computerized data base of archaic
or inaccurate data should be established and the patient and
physician should be notified before and after the data has been
purged. There should be no commingling of a physician’s
computerized patient records with those of other computer
service bureau clients. In addition, procedures should be de-
veloped to protect against inadvertent mixing of individual
reports or segments thereof.

(7) The computerized medical data base should be on-line to the
computer terminal only when authorized computer programs
requiring the medical data are being used. Individuals and
organizations external to the clinical facility should not be
provided on-line access to a computerized data base contain-

130

ing identifiable data from medical records concerning pa-

tients.

(8) Security:

A. Stringent security procedures for entry into the immediate
environment in which the computerized medical data
base is stored and/or processed or for otherwise having
access to confidential medical information should be de-
veloped and strictly enforced so as to prevent access to the
computer facility by unauthorized personnel. Personnel
audit procedures should be developed to establish a record
inthe event of unauthorized disclosure ofmedical data. A

roster of past and present service bureau personnel with

specified levels of access to the medical data base should
be maintained. Specific administrative sanctions should
exist to prevent employee breaches of confidentiality and
security procedures.

B. All terminated or former employees in the data processing
environment-should have noaccess to data from the medi-
cal records concerning patients.

C.’ Involuntarily terminated employees working in the data
processing environment in which data from medical re-
cords concerning patients are processed should im-
mediately upon tennination be removed from the comput-
erized medical data environment.

D. Upon termination of computer service bureau services for
a physician, those computer files maintained for the
physician should be physically turned over to the physi-
cian or destroyed (erased). In the event of file erasure, the
computer service bureau should verify in writing to the
physician that the erasure has taken place. (IV)

Appendix 5: Questionnaire

APPENDIX 5

QUESTIONNAIRE

1. What information is abstracted from the medical record and on

-computer?

 

 

 

 

 

 

 

a. How is this data used?

 

 

 

b. By whom?

 

 

c. How is this data obtained? Printout or photocopy?

 

 

 

2. Do procedures exist concerning who is authorized to add/delete

and/or change intormation on file?

 

 

 

 

a. How has this changed with the computer?

 

131

132

Who renders_this policy?

 

Has this policy changed with automation?

 

if yes, how?

 

How long have your medical abstracts been on computer?

 

II.

Where is the computer facility

housed?

 

Is it a limited access area?

 

What hardware is used?

 

What software is used?

 

where was it bought?

 

Assassi§esucisz

b.

133

what does it do (any restrictions?)

 

 

Is your system a private in-house system or is there outside
access?

 

Are dumb terminals used or p.c.’s?

 

how many terminals are there?

 

How were the employees trained?

 

Who has access to the system?

 

What are the backup measures?

 

What is the method of storage?

 

131+

10. Who renders the policy in this area?

 

a. has it changed with automation?

 

b. if yes, how?

 

4

c. if no, does the old policy suffice; if not, why not?

 

 

135

III. Belgégg 9f Information

1. How are requests for information handled?

 

 

 

 

a. internal requests?

 

 

b. external requests?

 

 

 

136
IV- Eaistiug sttsm
management

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

 

 

 

 

 

Emglsxsss

’1. What are. the concerns your employees have with the existing
system? -

 

 

 

 

Fullx Automated §xs§sm

‘ fléfléQQflQDE
1. In order of your highest priority, what are your concerns with
a fully automated system?

 

 

 

 

 

137

Emelsxss

1. What are the concerns your employees state they may have with a
fully automated record?

 

 

 

 

 

Qonfidgntiglity

1. Prompt confidentiality issue if not mentioned by respondent and
record response. '

 

 

 

 

 

 

 

 

 

2. Would you agree to an increase in (name #1 concern) if it decreased
the confidentiality problem? yes no don’t know

a. Where is confidentiality on your priority list?

high medium low

Appendix 6: Hospital Profiles

APPENDIX 6

HOSPITAL PROFILES

HOSPITAL 01
502 Beds, Private Facility

I-uatecs 9i Eaistids 525359

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

admission dates.

 

 

a. How is this data used?

Reviewing purposes

 

Administrative uses (quality assurance)

Research and statistical purposes

 

b. By whom?

Administrators

 

CPHA (research)

 

c. How is this data obtained7‘Printout or photocopy?

Standard response: Data obtained directly from the medical chart; the

 

chart is coded. Utilize photocopy. .

L
‘—

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response; The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

are now authorized to add/change, delete information per medical record

department personnel.

138

 

APPENDIX 6

HOSPITAL PROFILES

HOSPITAL #1
502 Beds, Private Facility

I-usssts 9i Esistins fixated

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

admission dates.

 

 

a. How is this data used?

Reviewing purposes

 

Administrative uses {quality assurance)

Research and statistical purposes

 

b. By whom?

Administrators

 

CPHA (research)

 

c. How is this data obtained?‘Printout or photocopy?

Standard response: Data obtained directly from the medical chart; the

 

chart is coded. Utilize photocopy. .

k
v—

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response; The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical record

_—__“

department personnel.

 

138

. 139

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

 

be if Y... he“?

 

4. How long have your medical abstracts been on computer?

' Since May 1981.

 

Ill essssaLSscusitX

1. Where is the computer facility housed?

In the medical record department.

 

." Is it a limited access area?

Yes.

 

2. What hardware is used?

Burroughs.

 

3. What software is used?

MedRec. Designed specifically for

abstracting and

sent to CPHA.

 

140

a. where was it bought?

Via the hardware.

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from the patient chart.

 

 

4. Is your system a private in-house system or is there outside
access?

Standard response: Private in—house.

 

5. Are dumb terminals used or p.c.’s?

Dumb.

 

a. how many terminals are there?

Three.

 

6. How were the employees trained?

By the medical record personnel staff.

 

,7. Who has access to the system?

Standard response: Transcriptionists and CEO’s in the department.-

 

.B. What are the backup measures?- .”

Nightly back-up onto tape.

 

 

 

.. ‘. . .A eqm~cc~—- -..-..-.— -.. v “a”..-

141

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The medical record department personnel.

 

a. has it changed with automation?

Yes.

 

b. if yes,'how?

Passwords that are changed every 6 months and identification numbers

 

for each employee.

 

c. if no, does the old policy suffice: if not, why not?

 

 

1h2

111- Bel ass at leissmatiee

1. How are requests for information handled?

Standard response: Copy the hard copy'ef the medical record according

 

to ”need" and who wants the information. Physicians have full access

 

to the chart.

 

 

a. internal requests?

Standard response: These requests go through the director/assistant

 

director of the department and again according to need.

 

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

11m

--..———.-aw~-y ——-—. -..—

IV- sistius sttse

assessment

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Interfacing with other systems

 

2. Duplication of entry

 

3. Time saver

 

 

 

Emulsxsss

1. What.are the concerns your employees have with the existing
system?

1. Duplication of screens and therefore having to go back-and-

 

forth

 

2. Screen glare

 

 

 

Fulix Autoéasgg Slates

assessment

1. In order of your highest priority, what are your concerns with
a fully automated system?

1. Adequate training of staff on system

 

2. Adequate time frame to implement system

 

3. Adequate amount of money for system implementation

 

 

 

1 ' S.——-. ...-5....- . -_.- .-~..—- o-oouo-Qvooe o_&--~..

Emelsxss

1: What are the concerns your employees state they may have with a
fully automated record?

1. Don’t know.

 

 

 

Cediidsutialitx

1. Prompt confidentiality issue if not mentioned by respondent and
record response.

Confidentiality is an “everyday concern to be maintained. It is not .
a problem at this point withcmgf system." Confidentiality is an
”absolute priority and breach of such is more important.than any

employee frustration problems.“ Concern with lawsuits on this

account.

 

 

 

 

2. Would you agree to an increase in employee frustration if it
decresed the confidentiality problem? ‘

yes no don’t know
3. Where is confidentiality on your priority list?

high medium. low

HOSPITAL #2
380 Beds, Public Facility

I-Natscs 9i Eaistieg Sxatss

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

...-~00

 

number, diagnosis, procedures, physicians involved, discharge and

v

admission dates.

 

a. How is this data used?

Physician use

 

Administrative uses (quality assurance)

 

Research and statistical purposes

 

 

b. By whom?
.Administrators . Physician use -
CPHA‘(research), Other medical staff.

..-.—

 

c. How-is thii data obtained? Printout or photocopy?

Standard response: Data obtained directly from the medical chart: the

 

chart is coded. Utilize photocopy.

 

2. Do procedures exist concerning who is authorized to add/delete
and/or.change information on file?

Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical record

 

department personnel.

1#6

1#7

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

L

b. if yes, how?;

 

45 How long have your medical abstracts been on computer?

Since 1983.

 

Ill esssesLSssscitx

1. Where is the computer facility housed?

Outside the hospital; connected by phone lines.'

 

'a. Is it a limited access area?

Yes.

 

2. What hardware is used?

IBM.

 

3. What software is used?

PAS PLUS. Designed specifically for abstracting and sent to

CPHA.

 

1M3
a. where was it bought?

From CPHA.

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from the patient chart.

 

 

4. Is your system a private in-house system or is there outside
access?

Standard response: Private in-house.

 

5. Are dumb terminals used or p.c.‘s?

Dumb terminals.

 

a. how many terminals are there?

Four.

6. How were the employees trained?

By the medical record personnel staff and the software company, CPHA.

 

7. Who has access to the system?

Standard response: Transcriptionists and CEO’s in the department.

 

B. What are the backup measures?

‘
- -... a..- —-—-—-.-

Nightly back-up onto tape.

 

vs- vse‘ '1 n w - " -0

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The medical record department personnel in conjunction with CPHA.

 

a. has it changed with automation?

Yes.

 

b. if yes, how?

Passwords that are changed every 8 months.

 

 

c. if no, does the aid policy suffice; if not, why not?

 

 

.. .. Iss<d a-_p‘-a—--..-'.-.-a— ‘0---.-IKr--.-

150

111- Release at leisceatiee

1. How are requests for information handled?

Standard response: Copy the hard copy of the medical-record according

 

to “need" and who wants the information. Physicians have full access

 

to the chart; particularly used for research purposes. This includes

_'

administrative use/users.

 

a. internal requests? ‘ -

Standard response: These requests go through the director/assistant

 

director of the department and again according to need.

‘—

b. external Requests?

Standard response: This is state-mandated as to what outside parties

__‘_A

have access to this information.

151"

Eaissins stssm

nansasmsni

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Retrievability

 

W

2. Loss of data once input onto computer

 

3. Need to interface with other departments in the hospital

 

 

 

Emalexsss

1. What are the concerns your employees have with the existing
system?

1. Time loss on the system because some functions can be done faster

 

_.manually.

2. Computer gnxietyt

 

Esllx QHSQEQSEQ sttsm
assessment

is In order of {our highest priority, what are your concerns with
a fully au omated system?

1. ”Having our own software package so that it configures to our

 

specific hospital needs."

 

 

 

 

* - . . c - o v. ..."-..

152

Emaiexss

1. what are the concerns your employees state they may have with a
fully automated record?

1. Don't know.

 

 

 

 

 

Csniidsntislitx

1. Prompt confidentiality issue if not mentioned by respondent and
record response.

Confidentiality.is a high priority. Medical record personnel and output

 

of work is under much more "critical observation today with the health

 

care changes in medicine." Therefore, concerned with confidentiality

 

since more individuals have access to the information. To date, ”we

L

have had several hardware problems" and this issue doesn't take

‘—

precedence at this time.

 

 

 

 

2. would you agree to.a decrease in retrievability of data if it '
decresed the confidentiality problem? '

yes no don’t know
3. Where is confidentiality on your priority list?

--D19D medium . . low- - . ,. ".,,J_ ._

HOSPITAL #3
462 Beds, Private Facility

I-ustucs ei Eaisiina sttsm

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

number, diagnosis, procedures -, physicians involved, discharge and

 

 

admission dates.

 

a. How is this data used?

Physician use

7

Administrative uses (quality assurance)

 

 

Research and statistical purposes

 

b. By whom?

Administrators

 

Physician use

 

c. How is'this data obtained? Printout or photocopy?

Standard response: Data obtained directly from the medical chart; the

 

chart is coded. Utilize photocopy.

 

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical record

V

department personnel.

 

153

.m ’154"" - - - - - -_,_“--__in

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

 

b. if yes, how?

 

‘— cr—

4. How long have your medical abstracts been on computer?

Since 1980.

 

- LI... assessifisssciix

1. Where is the computer facility housed?

Inside the medical record department.

 

a. Is it a limited access area?

Yes.

 

2. What hardware is used?

IBM.

 

3. What software is used?

Arthur Anderson Case-Mix System; there own software for abstracting

 

...... .. .... - c a. o .- -_—- -§ ...-In...

155

a. where was it bought?

Developed in-house for their own hospital use/needs

 

w v—

b. what does it do (any restrictions?)

Set up for medical abstracting of information from the patient chart.

 

 

4. Is your system a private in-house system or is there outside
access?

Standard-response: Private in-house.

 

fl e

5..Are dumb terminals used or p.c.'s?

Personal computers

 

a. how many terminals are there?

Five

 

A. How were the employees trained?

By the medical record personnel staff

 

7. Who has access to the system?

Standard response: Transcriptionists and CED’s in the department.

 

B. What are the backup measures?

Nightly back-up onto tape.

 

 

5.... .. -..-—-——>o— --——-....A.._-

 

156

9. What is the method of storage?

Stored on tape;

 

10. Who renders the policy in this area?

The medical record department personnel

 

a. has it changed with automation?

Yes.

 

b. if yes, how?

Passwords and identification numbers.

 

c. if no, does the old policy suffice; if not, why not?

 

 

157

1. How are requests for information handled?

Standard response: Copy the hard copy of the medical record according

 

to "need" and who wants the information.

. ‘ i—

a. internal requests?

o-Standard response: These requests go through the director/assistant

- ‘e
-

director of the department and again according to need.

' v t

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

158

IV- Existing fixstse

assessment

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Quality control over the employee on the system

 

 

 

 

 

Emnlexsss

1. What are the concerns your employees have with the existing
system?

1. Competing for mainframe time

 

2. An increase in backlog of work

 

3. Losing input once information put onto computer

w

 

 

Eullx eutemsted sttsm
management .

1. In order of your highest priority, what are your concerns with
a.fully automated system?

1. ”Having a system that will improve working conditions"

 

2. Need adequate time to implement the system hospital-wide

 

 

 

 

Emnlexss

1. What are the concerns your employees state they_may have with a
fully automated record? .

1. Worried about the increase use of computer displacing personnel

in their present working conditions.

 

 

 

Ceniidsutislitx

1. Prompt confidentiality issue if not mentioned by respondent and
record response.

Confidentiality is not a present concern with the existing system;
but "(1) see the need for.it to be so with a fully automated system.“

_‘

Therefore sees the value in planning ahead with the implementation

of a fully-automated medical record.

 

 

 

 

 

2. Would you agree to a decrease in quality control over employees
if it decreased the confidentiality problem? .

VII no semi; tees
3. Where is confidentiality on your priority list?

DIED medium low

- . .. _.-..-—-—. .— ..~-‘.—-- A. o. - V -- <-.o--. -—--—-~—-‘

HOSPITAL #4
456 Beds, Public Facility

I-ustscs ei Esisties fixstss

I. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involied, discharge and

 

admission dates, number of days in ICU, medications and whether the

 

_‘

patient had been transferred to the hospital.. '

 

a. How is this data used?

Physician use

 

 

 

b? By whom?

Administrators

w

CPHA (research use)

 

 

c. How is this datp obtained? Printout or photocopy?

Standard response: Data obtained directly from the medical chart; the

 

chart is coded. Photocopy indepth information; printouts for summaries.

an.

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file? ' '

Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical record

 

department personnel.

160

161

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

 

b. if yes, how?

4. How long have your-medical abstracts been on computer?

Since 1980.

 

ii. assessifissucitx

1. Where is the computer facility housed?

In the medical record department.

 

.a. Is it a limited access area?

Yes.

2. What hardware is used?

Data General.

 

162

3. What software is used?

PAS PLUS.

 

a. where was it bought?

CPHA.

 

b. what does it do (any restrictions?)

1. Set up for medical abstracting of information from patient chart.

 

2. Research/statistical purposes.

 

4. Is your system a‘private in-house system or is there'outside
access?

Standard response: Private in-house.

 

5. Are dumb terminals used or p.c.’s?

Dumb terminals

 

a. how many terminals are there?

Eight

 

6. How were the employees trained?

By the medical record personnel staff

 

7. Who has access to the system?

Standard response: Transcriptionists and CE57s in the departmEnt.

 

163

B. What are the backup measures?

Nightly back-up onto tape.

. --.—.-..-.

 

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area? _

The medical record department personnel.

 

a. has it changed with automation?

Yes.

 

b. if yes, how?

Passwords are used to access the system

 

 

c. _if no, does the old policy suffice; if not, why not?

 

 

164

III- lessss Qfi Iniecmstisn

1. How are requests for information handled?

Standard responseiwCopy the hard copy qf-the medical record according

 

r
C

to “need“ and who wants the.information. No-change with the computer;

 

generally give the paper copy of the_record-to-the.individual

 

fl

requesting the infocmation.

a. internal requests?

Standard response: These requests go through the directorfassistant

 

director of th‘ department and again according to need.

 

O

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

165

IV- Eaisiins fixsism

Uifléflfimfifli

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Retrievability

 

2. Accuracy of the information that is being input to the system

 

 

 

Emelexssa

1. What are the concerns your employees have with' the 'existing
system? '

1. Keyboard problems

2. Training, which should be adequate and done upon hiring

 

 

- Esllx fistssstsd stiss
management

1. In order of your highest priority, what are your concerns with
a fully automated system?

1. Accuracy: "getting the correct information on'the right patient.“

2. Need adequate time to implement the system hospital-wide.

 

...- - .— ~ A — --.—. --

 

166

Emnlexse

1. What are the concerns your employees state they may have with a
fully automated record?

1. Don’t know.

 

 

 

 

Ceniidentialitx

l. Prompt confidentiality issue if not mentioned by respondent and
record response.

Agrees that confidentiality is an_importanf issue, and states

v f

“employees have expressed some concern in this area" given a fully

automated system.

 

 

 

 

 

2. Would you agree to a decrease retrievability of data if it
decreased the confidentiality problem? '

yes ‘ no don’t know
3. Where is confidentiality on your priority list?

.Diflh._- ““41““ ..-199._.

’ w

HOSPITAL #5
SSS Beds, Public Facility

I-ustscs 9i Esistins 5223:;

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

number, diagnosis, procedures, physicians involved, discharge and

 

 

admission dates.

 

a. How is this data used?

Physician use Research (statistical analysis)

 

Administrative uses Billing/DRG’s '

 

 

-b. By whom?

Acministrators . Other medical staff

 

Physicians

 

c. How is this data obtained?'Printout or photocopy?

Standard response: Data obtained directly from the medical chart; the

 

chart is coded. Utilize photocopy. '

 

2. Do procedures exist concerning who is authorized to add/delete
' and/or change information on file?

Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical record

 

department personnel.

 

.167

168

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change. ”Put computer changes on top of old policy for ‘fit’.

 

b. if yes, how?

 

4. How long have your medical abstracts been on computer?

Since.l975.

 

1. Where is the computer facility housed?

Outside the medical record department

V" v——

 

a. Is it a limited access area?

YES.

 

2. What hardware is used?

IBM

 

3. What software is used?

PCS-ADS: developed own software package for abstracting

169w

a. where was it bought?

Program developed in-house.

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart.

 

 

4. I..y0ur system_a.priyate in-house’Dystemwoc—is.there outside
access? ‘ .

Standardizesponse: Private in-house.

 

5. Are dufib’terminals'used or p.c.'s?
Dumb terminals

a. how many terminals are there?

Twelve

 

6. How were the employees trained?

By the medical record personnel staff

 

7. Who has access to the system?

Standard response: Transcriptionists and CEO’s in the department.

 

8. What are the backup measures?

Nightly back-up onto tape.

 

170

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The medical record department personnel.

 

a. has it changed with automation?

Yes.

 

b. if yes, how?,

Passwords are used to access the system

 

 

c. if no, does the‘old policy suffice;

if not,

I

why not?

 

 

171
IV- Eaistins fixstsm

assessment

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Networking/interfacing with other systems in the hospital

 

2.'A more comprehensive system so the computer can do more

 

3. Ease of managing data (easier manipulation of data)

 

 

Emelexsss-

1. What are the concerns your employees have with the -existing
system?

1. No problems

 

 

 

- : Esllx estsmatss fixstsm '

flansssmsnt

1. In order of.your highest priority, what are your concerns with
a fully automated system? '

1. Interfacing with more computer systems throughout the hospital

 

 

 

\

172

Emelexes

1. What are the concerns your employees state they may have with a
fully automated record?

1. Adequate training on new system

 

 

 

 

Confidentiality

1. Prompt confidentiality issue if not mentioned by respondent and
record response. '

Confidentiality is an "assumed" priority in medical records and
considered with any new policy development. The present system is

“highly sophisticated" and "no problems" to date. Less security

exists.uith the manual record; the computer allows for segmentation of

asthe information so tonfidentiality is more guarded in a computerized

—v

.system. The real problem is that technology is changing so fast it’s
difficult to make policies/plans for the future. The computer is “just
another tool; confidentiality is mentioned as an issue by those who
ana not familiar with a good system." States those individuals who work
alot with computers are less apt to find them intimidating and

q.

”less apt to see a breach of confidentiality as a problem.”

_a;

2. Would you agree to decreased networking of systems if it
decreased the confidentiality problem? '

yes . no don’t know
3. Where is confidentiality on your priority list?

high medium. 10w

HOSPITAL #6
243 Beds, Public Facility

I-flatsce oi Eaistiaa fixatee

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

 

admission dates.

fi

 

' a. How is this data used?

Research (statistical analysis)

 

1' 6 —"“-—

b. By.whom?

' CPHA (reseanch)~ fl .

P

 

 

c. How is this data obtained? Printout or photocopy?

Standard responsezfoata obtained directly from the medical chart; the

 

chart is coded. Utilize photocopy.

 

2. Do procedures exist concerning who is authorized to addldelete
and/or change information on file?

Standard response: The chart is first coded then input onto computer.'

 

These individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical record

 

department personnel.

 

173

174

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

....-.~- ...... .-.

‘ .-.--.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

 

b. if yes, how?

 

4. How long have-youe medical abstracts been on.computer?

Since April, 1985.

 

1. Where is the computer facility housed?

Outside the hospital

 

a. Is it a limited access area?

Yes.

 

2. What hardware is used?

IBM

 

3. What software is used?

~ ‘ .

PAS PLUS

‘

Nightly back-up onto tape.

175

a. where was it bought?
CPHA, the software company
b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart}

 

_4. lsuyour‘syitemca.privateminnhouse system or is-there outside

.‘eccess?

Standardsresponse: Private in-house.

 

‘3. Aremdumb terminals—used‘or p.c.’s?

Both are used

 

a. how many terminals are there?

Seven dumb terminals and 1 p.c. (used only for processing of DRB’s)

 

6. How were the employees trained?

By the medical record personnel staff and CPHA personnel

 

7. Who has access to the system?

Standard response: Transcriptionists and 680’s in the department.

 

a. What are the backup measures?

176

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The data processing department

 

a. has it changed with automation?

Yes.

 

b. if yes, how?

Passwords are used to access the system along with identification .

 

,numbers: also have security codes per job function to limit access

 

c. if no, does the old policy suffice; if not, why not?

 

 

177

III. Release Qfi Information

1. How are requests for information handled?

Standard response: Copy the hard copy of the medical record according

 

to "need" and who wants the information. Physicians have full access

 

to the chart; particularly used for research purposes. This includes

O

adminiStrative use/users.

 

a. internal requests?

Standard response: These requests go through the director/assistant

director of the department and again according to need.

 

b. external nequests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

178

IV- Esistioa sttsm

Uiflégfiflifli

1. In order of your highest priority, what are your concerns as a-
” manager with the existing automated record?

1. Backloading of information

 

 

 

59219133:

1. What are -the-coneerns your employees have with the existing
system?

1. Down time with the computer

 

2. Response time of'computer

 

 

 

 

Esllx automated sttsm
management

1. In order of your highest priority, what are your concerns with
a fully automated system?

1. Retrievability of information: “need to provide information to

 

those who need it fast; we are a service department."

 

.-

 

179

. —-.-.o—-.——— u—.- - -..---..— .

Emaiexss

1. What are the concerns your employees state they may have with a
fully automated record?

1. Don’t know of any

 

 

 

'Csniissotiaiiix . 't

1. Prompt confidentiality issue i-f-not mentioned'-by'respondeat- and
record'response.

Confidentiality is not "my first Cdecern but of- course it is

—I

important. “ Str ic -t security codes thats sLsst in-depaezmgujnprecluds

_
I 7'" ‘7'

any “problems with confident tiality with our system concesned with

A
j— ' :

unauthorized individuals getting into system.- through sharing of pass-

words therefore compromising confidentiality.

 

 

 

 

2. Would you agree to decreased retrievability of data if it
decreased the confidentiality problem?

yes no 922’; tuss-
13. Where is confidentiality on your priority list?

high medium low I i I ‘ ... -~,_ ,-.

HOSPITAL #7
410 Beds, Public Facility

I. Nature gf 5:: istin _g 3v gtgm

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

 

admission dates.

 

a. How is this data used?

lResearch (statistical analysis) Administrative

 

Physician use Billing/DRG’s

 

 

be By whom?
CPHA (research) ‘ -Administrators

Physicians Third-party (Insurance)

 

c. How is this data obtained? Printout or photocopy?

Standard response: Data obtained directly from the medical chart; the

 

chart is coded. Utilize photocopy.

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response: The chart is first coded then input onto computer.

v.

 

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical recard

 

department personnel.

 

180

181

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department p-rsonne1.

 

a. Has this policy changed with automation?

No change.

 

b. if yes, how?

4. How long have your medical abstracts been on compfiter?

Since l982

¥ .A.

1. Where is the computer facility housed?

Outside the hospital

 

Ia. Is it a limited access area?

Yes.

 

2. What hardware is used?

Data General

 

3. What software is used?

PAS PLUS

 

182

a. where was it bought?

CPHA, the software company

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart.

 

 

" 4. Is your system a'private in-house system or is there outside.
'- access?

Standeed-response: Private in-house.

 

‘5. Are dumb terminals used or p.c.’s?

Dumb terminals

 

a. how many terminals are there?

Four

6. How were the employees trained?

By the medical record personnel staff and CPHA personnel

 

7. Who has access to the system?

Standard response: Transcriptionists and CEO’s in the department.

 

B. What are the backup measures?

Nightly back-up onto tape.

 

183

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The data processing department

 

a. has it changed with automation?

-Yes.

b. if'yes, how?

Passwords are used and identification numbers to access the system '

 

' and get on-line.

c. if no, does the old policy suffice; if not, why not?

0

 

 

181*

III. fielgggg Qfi Information

1. How are requests for information handled?

Standard response: Copy the hard copy ef the medical record according

 

to "need" and who wants the information. Physicians have full access

L

to the chart.

 

 

 

a. internal requests?

Standard response: These requests go through the director/assistant

—L— —

director of the department and again according to need.

 

 

 

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

185

. - ...- «.---—I-o-.--'OO ...—0% a...

IV- Eaistinn sttsm

management

1. In order of your highest priority, what are Your concerns as a
manager with the existing automated record?

1. Time saver: the "computer allows for alot of short-cuts.”

 

 

 

 

‘Emalexsea

1. What are the concerns Your employees have with the existing
system?

1. Problems with the keyboard

 

 

 

 

 

Esllx flutemstse sttss
management

1. In order of your highest priority, what are your concerns with
a fully automated system?

1. Reliability of the system: "alot of people will be accessing the

 

system once it’s fully automated and I’m concerned if that won’t

 

hurt reliability of what is put in correctly or otherwise.“

 

. 186. .. _ . _. .-- . .-.-..” . ---,
Emnlexes

1. What are the concerns your employees state they may have with a
fully automated record?

1. Don’t know of any

 

 

 

 

 

Qonfidgntiélitx

l. Prompt confidentiality issue if not mentioned by respondent and
' record response.

Confidentiality is more important than any other "problem we deal with."

 

‘7'

States that it should be guardeev'r? .ted as the High.est priority over '

- "' 3’

- any other “pressing need.“
"'7‘ —;—v

 

 

 

 

 

 

 

 

 

2. Would you agree to decreased reliability of information if it
decreased the confidentiality problem?

yes no don’t know
3. Where is confidentiality on your priority list?

high medium low

HOSPITAL #8
529 Beds, Private Facility

I-Natucs ei Eaistina §xstem

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

 

admission dates.

 

a. How is this data used?

Research (statistical analysis) Administrative

 

Physician use

 

 

 

 

ba-Oyfwhom?
CPHA (research) Administrators
Physicians
c. How is this data obtained? Printout or photocopy? 0

Standard response: Data obtained directly from the medical chart: the

 

chart is coded. Utilize photocopying and printouts.

 

'

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

' Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

 

v—

are now authorized to add/change, delete information per medical record

 

department personnel.

 

187

188'

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

 

b. if yes, how?

 

' "V 7 Vi

4. How long haVe your medical abstracts been on camputer?

Since 1981

J _-_

1. Where-is the computer facility housed?'

In the medical record department

 

a. Is it a limited access area?

Yes.

 

2. What hardware is used?

Data General

 

3. What software is used?

PAS PLUS

‘189

a. where was it bought?

CPHA

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart.

 

 

4. Is your system a private in-house system or is there outside
access?

Standard response: Private in-house.

 

5. Are dumb terminals used or p.c.'s?

Dumb terminals

 

a. how many terminals are there?

One

 

b. How were the employees trained?

By CPHA

 

7. Who has access to the system?

 

Standard response: Transcriptionists and CED’s in the department.

8. What are the backup measures? -

Nightly back-up onto tape.

 

190

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The medical record department

 

a. has it changed with automation?

Yes.

 

w.—
.

- ~b.dif yes, how?

-Passwords and idestification numbers are used to log into system

 

 

c. if no,‘dees.the-o&d-pplicy suffice; if not, why not?

 

 

191

111- Salsas: Qt luiecmeties

1. How are requests for information handled?

0

Standard response: Copy the hard copy of the medical record according

+
"I’

to “need" and who wants.the information. The same process is used‘

 

as with the manual record.

 

 

a. internal requests?

Standard response: These requests go through the director/assistant

 

director of the department and again according to need.

 

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

192

IV- Esistisa Sxaiem

Uifllfiimifli

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Time saver

 

2. Undersold in storage capacity

 

 

 

 

Emslexsss

r. What are the concerns ydflr employees have with the existing
system?

1. EmpLOyees like the system’amd woutcn’t go-back to manual processing

 

... T v
' a

of information; don’t kndwfofi—amyfipuoblemzjconcerns

 

 

 

assessment

1. In order of your highest priority, what are,your concerns with
a fully automated system?

1. Confidentiality

 

2. Security

 

3. Doctor cooperation on the system: "their ccoperation could make or

 

break the system”

 

4. Adequate training of all the staff accessing the system

 

193

Emelexea

1. What are the concerns your employees state they may have with a
fully automated record?

1. Not aware of any

 

 

 

 

 

Qeniigestialitx

1. Prompt confidentiality issue if not mentioned by respondent and
record response. '

Although confidentiality was cited without interviewer prompting,

 

7

director states that “it’s a dream-world to think it (confidentiality)

will be covered in policy-making." Ethically, confidentiality is a

 

priority, but realistically the economies of retrieving information

 

is more‘important than trying to prevent breach of confidentiality.
"I was on the planning committee for this-computer system and con-

fidentiality came up after there was a problem with physician breach.“

 

 

 

2. Would you agree to a decrease in time-saving measures if it.
decreased the confidentiality problem?

yes 99 don’t know
3. Where is confidentiality on your priority list?

high medium low

HOSPITAL 09
210 Beds, Public Facility

I-uatucs ei Esisiisn fiestas
1. What information is abstracted from the medical record and on
computer?
Patient age, sex, religious affiliation, patient identification
number, diagnosis, procedures, physicians involved, discharge and

admission dates.

 

 

a. How.is this data used?

Research (statistical analysis) Administrative -

 

Physician use c-“ -BillingflDR6’s .U

' be BY. WOO? .

CPHA (research) , . Administrators

 

Physicians

 

c. How is this data obtained? Printout or—photocopy?

Standard response: Data obtained'directly from the medical chart: the

 

"

hart is coded. Utilize photocopy.

 

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response: The chart is first coded then input onto computer.

A

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical record

 

department personnel.

 

19a

195

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

—. v

3. Who renders this policy?

Standard response: Medical record department personnel.

 

‘—

a. Has this policy changed with automation?

No change.

 

b. if yes, how?.

 

.4?,How,long have your medical abstracts been on computer?

Since 1953

 

l

IH
'e

|\
an
I‘D
IE
IT
nw
Irf
K

6553:: s

1. Where is the computer facility housed?

In the medical record department

 

a. Is it a limited access area?
Yes.
2. What hardware is used?

IBM

 

3. What software is used?

PAS PLUS

 

196

a. where was it bought?

CPHA

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart.

 

 

_4. Is your'system a private in-house system or‘is‘tbere‘outside
access? -

Standard response: Private in-house.

 

f

5. Are dumb terminals used or p.c.’s?

Dumb‘terminals

+

at how many terminals are there?

One

 

6. How were the employees trained?

By CPHA and the staff in the medical record department

 

7. Who has access to the system?

Standard response: Transcriptionists and CED’s in the department.

 

r

B. What are the'backup measures?

Nightly back-up onto tape.

 

.. ... ... - - ~ ...-...”. - “.-.: ..t._ .- .-. ...-,-.. _. -. ---.-- ——..-——-—.- ..~ - .-..- . ... a.- .o a.--'~ --.- 0- - >-—-. W

197

9; What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The medical record department in conjunctipn with CPHA

 

au-fi§§°it>q&§fl93d‘with automation?

YE‘ s

 

-4b;;if yes? how?

,.Pesswords-end-identifisation numbers are used

 

—f

 

c. if no, does the old policy suffice: if not, why not?

0

 

198

III- Balsass 9i leiscmatien

,1. How are requests for information handled?

Standard response: Copy the hard copy of the medical record according

 

T —v— w-

to “need“ and who wants the information. This hasn’t changed with the

—

 

computer.

 

__‘

a. internal requests?

Standard response: These requests go through the director/assistant

 

director of the department and again according to need.

 

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

199
Iv. Eaistinn firstsm

Ulfliflflmlfli

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Time saver ‘

2. Networking with other systems in the hospital, to enhance

“compatability”

 

 

 

Emelsxsss
1. What are the-concerns your employees have with the existing
system?

1. Time-saver

 

 

-v ” Estlxresteestse sttsn
management

1. In order of your highest priority, what are'your concerns with
a fully automated system?

1. Backup of information: "will always have to have hard copy"

 

2. Downtime and getting behind because "so many others are accessing

 

the system

 

3. Accuracy: "will so many people be in a hurry and make more mistakes

 

on the computer and hurt accuracy of information?”

 

200 a,“

Emslexss

1. What are the concerns your employees state they may have with a
fully automated record?

1. Frustration with downtime

 

 

 

 

Eeeiiesntialitx

1. Prompt confidentiality issue if not mentioned by respondent and
record response.

Confidentiality is the most important concern. ”If hackers are in

 

government records then it should also happen with medical records."

 

_‘

States the real concern and worry should be with internal hackers and

 

internal breaches of confidentiality. "The biggest problem are doctor’s

 

trying to find out information about other doctors." This is where the

 

greatest breach of confidentiality occurs according to this director and

 

will become worse with a fully automated system.

 

 

 

 

2. Would you agree to decreased backup measures if it decreased
the confidentiality problem?

ye; no don’t know
3. Where is confidentiality on your priority list?

high medium ' low

HOSPITAL #10
531 Beds, Public Facility

I-Batscs 2i Eaisting sttsm

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

 

admission dates.

 

a. How is this data used?

Administration

 

Billing/DR8?s

 

b: By whom?

Acmi ni str‘at'ors ,

 

_Third-party (Insurance)

_— w—'

A ‘ n

c. How is this data obtained?—Peintout or photocopy?

Standard response:-Qata obtained diféctly from.the-medical chart: the

 

chart is coded. Utilize photocopy.

 

—— r

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical record

 

department personnel.

 

201

202

.

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change. . .

 

b. if yes, how?

4. How long have your medical abstracts been on'computer?

Since 1982

 

ll; assessifissscitx '

1. Where is the computer facility housed?

Outside the medical record department

 

a. Is it a limited access area?

Yes.

 

2. What hardware is used?

IBM

 

3. What software is used?

DataCare

 

203

a. where was it bought?

Don’t know

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart.

 

 

4. Is your sfistem a private in-house.syetem-oc-isgthe:eeoutside
.aczess? '

~Standard responaeraPrivata in-house.

-_ _. _-
T o '— r‘. T
- g o
o
a-

5. Are dumb terminals used or p.c.’s?

Dumb terminals

 

O

a. how many terminals are there?

Six

 

6. How were the employees trained?

By the staff in the medical record department

 

7. Who has access to.the system?

Standard response: Transcriptionists and CEO’s in the department.

8. What are the backup-measures? .. -, u- -

Nightly back-up onto tape.

 

. ”a- 0-0—» v-n . g o - -.. ..— ..--.-c-w --. -..—.-. .-- - .- ...-poo .- O I ..I--.--M

,-.—.-m ———r-—--o~-..-~..-,

20H

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The data processing department

 

a. has it changed with automation?

YRS.

b. if yes, how?,

Passwords and identificationtnumbers are used along with security

 

codes per job funtion, to cut down amount of access

 

c. if no, does the,o1d policy suffice: if not, why not?

 

 

205

111- Efilfiéfifi Qi lOiQCEéSiQO

1. How are. eefiaests for information handled?

Standard-rssponser Copy the hard copy of the medical record according

 

i‘VVV

ts-"needflsand-who- wants the information. It’s still the same as with

 

'7

the manualerecord; have to have a “certificate of need.“

 

' s. internal-requests?

'Standsrd response: These requests go through the director/assistant

 

director of the department and again according to need.

 

b. external requests?

Standard response: This is state-mandated as to what outside parties .

 

have access to this information.

 

Uassasmsnt

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Implementation of the system

 

2. Networking with other systems in the hospital to avoid duplication-

 

of process

 

 

 

Emnldxsss

1. What are the concerns your employees have with the existing
°system? '

I

1. Duplication of screens

‘ . 4 ~
-—

2. Having to go back-and-forth on screen

1"—

3. Time loss on system

 

 

 

l'fl

all! fistseatss.§xatss
management

1. In order of your highest priority, what are'your concerns with
a fully automated system?

1. Adequate training: "There should be a first level of training and

 

then train all the other departments; this would be optimal."

 

 

 

207

~— .. ...--. .—.---o.¢-a-a-.oo~a.-.-—-o.'-~

Emalexss

1. What are the concerns your employees state they may have with a
fully automated record?

1. Not aware of any of their concerns with this.'

 

 

 

 

stiissntislitx

l. Prompt confidentiality issue if not mentioned by respondent and
record_response.

Acknowledges confidentiality will be a problem with a fully automated

 

system, but "not automated enough now for it to be a problem.” States

 

that training is and should be the utmost priority: “adequate training

 

‘v

could control the internal problems of breach.“ Believes that theres is

 

not a fool-proof system to insure confidentiality: Atleast by training

 

the staff well, there could be some element of control over the quality

 

of information provided. Unless someone could interpret the codes,

 

T

whether or not they could get into the system wouldn’t really matter.

 

”Need to interface well and have a good internal network of systems"

A

over any concern of confidentiality.

 

2. Would you agree to decreased interfacing among systems if it
decreased the confidentiality problem?

yes up don’t know
3. Where is confidentiality on your priority list?

high -mssiss low

- .. . ..a..--~--“--fi-.-~----

HOSPITAL #11
209 Beds, Public Facility

I-flstscs st aistins Sxatse

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

 

admission dates.

 

a. How is this data used?

Administration Research

 

.Billing/DRG’s Physician use

 

b, By whom?

Administrators Research

Physicians

c.‘How is this data obtained?-Errnteut-or-photocopy?

Standard response: Data obtained-directly from the medical chart; the

 

T

chart is coded. Utilize-photocopy.

 

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record,

 

are now authorized to add/change, delete information per medical record

 

department personnel.

 

208

209

a. How has this changed with the computer?

Standard response: No change; same as_with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

 

b. if yes, how? ’

 

4. How long have your medical abstracts been on computer?

Since 1983

 

lls assessLSssacitx

1. Where is the computer facility housed?'

Outside the hospital

 

l

a. Is it a limited access area?

Yes.

 

2. What hardware is used?

IBM

 

3. What software is used?

Intermountain Health Care

 

210

a. where was it bought?

Out of Salt Lake City, through IBM

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart.

 

 

4r Is your system a pcivate in-house system or is there outside
-1 access? - '- . .-

Standard response: Private in-house.

 

5. Are dumb terminals used or p.c.’s?

Dumb terminals

 

a. how many terminals are there?

Two

 

6. How were the employees trained?

By both the staff in the department and the software company

 

7. Who has access to the system?

Standard response: Transcriptionists and CEO’s in the department.

 

B. What are the backup measures?

Nightly back-up onto tape.

 

211 "

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

.The.medical record department

 

a.{has it changed with automation?

...

Yes.

4?.
1

'——r T '—

b. if yes. how?

Passwords and identification numbers are used arong‘with2security

 

codes per job funtion.

 

c. 'if no, does.the old policy suffice; if not, why not?

 

 

212

III. Eglgggg 9: Information

'- l? Howzare requests for'fnformation handled?

Standard response: Copy the hard copy of the medical record according

 

to'"need”-and-who=wants the information. There hasn’t been any.change.

 

 

a. internahIFeQuests?

Standard response; These requests go through the director/assistant

 

director of the department and again according to need.

 

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

213.H_"_-.. m.. . .----__u

IV- Eaistina sttsm

Uifllflfifiifl:

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Downtime of system

 

 

 

Emfilexsss
1. What are the concerns your employees have.with the existing
system? ’

1. Don't know; haven’t had any problems

 

 

. 52m easement mm
Ulflifllfllfil ,

1. In order of your highest priority, what are your concerns with
a fully automated system?

1. Good training: "I’m really worried about this aspect; that there

 

won't be enough time to learn and/or teach everyone adequately."

 

 

 

 

21k
Emnlexss

1. What are the concerns your employees state they may have with a
fully automated record? .

1. Don’t know

 

 

 

 

 

Confidentiality

l. Prompt'tonfidentiality issue if not mentioned by respondent and
record response. .

Agrees that confidentialitysuill be a problem with a fully automated

v.— — --

systemgbecauee “peoplewcan access more easily the information they want

 

 

 

once it is on'computee." However, if training is not adequate, then

tnying to guard-confidentiality becomes a moot issue. "Without good

 

training, and part of that is instruction of confidentiality, then

T? -- __

decreasing confidentiality problems is of no benefit. States the

 

economics of retrieval of information'displces the ethics of patient.

 

rights because of the "amount of information needed and it’s needed

QUleIY. u

2. Would you agree to an increase in downtime if it decreased
the confidentiality problem?

yes g9 don’t know
3. Where is confidentiality on your priority list?

high medium low

HOSPITAL #12
137 Beds, Private Facility

I-ustucs 9i Eaiaiina fixetem

1. What information is abstracted from the medical record and on
computer?

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

 

admission dates.

v —-w- 7

 

a. How is this data used?

Administration Research

 

Physician use‘

 

 

b. By whom?

Administrators Research

 

Physicians

 

c. How is this data obtained? Printout or photocopy?

Standard response: Data obtained directly from the medical chart; the

 

chart is coded. Utilize photocopy.

 

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

are now authorized to add/change, delete information per medical record

 

department personnel.

 

.215

216 “" " ~u~~—~~-_euuuu

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

3. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

 

b. if yes, how?

.
’

4. How long have your medical abstraofiefipeen'on-computer?

Since 1981

 

II; esesesZ§seucit¥

'1. Whereiis the computer-facilitYThoused?

Outside the medical record department

 

a. Is it a limited access area?

Yes.

 

2. What hardware is used?

IBM

 

3. What software is used?

bans PLUS . --

 

217

a. where was it bought?

From CPHA

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart.

 

 

4; Is your system a private in-house system or’ts thereioutside
access? ‘ - .

'

Standard responsei-Private inchouse.

 

.5; Are dumb terminals used or p.c.'s?

Dumb terminals

 

w —'—
a

a. how many terminals are-there?

One

 

6. How were the employees trained?

By CPHA staff

 

7. Who has access to the system?

Standard response: Transcriptionists and CEO’s in the department”

 

8. What are the backup measures?

Nightly back-up onto tape.

 

—. -..—“.....- .-..9-- -~---

-218.-.

.--_O'-'.~‘-We-o-'Hv~ ~

9. What is the method of storage?

Stored on tape.

 

10. Who renders the policy in this area?

The medical record and data processing departments

 

'a. has it changed with automation?

Yes.

 

b. if yes, how?

Passwords and identification numbers are assigned to the employees

_‘,

 

accessing the system

.V

 

c. if no, does the old policy suffice; if not, why not?

 

 

‘-.

219

III- Eslssss ei Iniecmstien

1. How are requests for information handled?

Standard response: Copy the hard copy of the medical record according

 

to "need“ and who wants the information.

 

 

 

a. internal requests?

Standard response: These requests go through the director/assistant

 

*‘r i

director of the department and again according to need.

 

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

220 '_‘w“"”
IV- Esistina sttsm
management

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record? '

1. Have no problems with the existing system

 

 

 

 

Emalexeea

1. What are the concerns your employees have with the existing
system?

1.1Less error rate with the software

 

 

 

 

Eullx astemaisd fixstsm
management. '

1.-In‘order-of your highest priority, what are your concerns with
* a fully automated system?

1. Confidentiality: "If there is going to be alot of people on the
system, have to make sure that proper security codes keep the
system safe.“

2. Time saver

 

221

_-ao--'-a~.. up .- ...-......—— -- ----—~.

Eealsxss

1. What are the concerns your employees state they may have with a
fully automated record? '

1. Don’t know

 

 

 

 

 

Seeiissntisiitx

l. Prompt confidentiality issue if not mentioned by respondent and '
record response. .

Expressed confidentiality as the greatest concern. States that the

 

advantages of computer-friendliness and time saving measures shouldn’t.

1’— f V.

“overdshadow” the patient’s right to confidentiality.

L
——V r—

 

 

 

 

 

2. Would you agree to a decrease in time-saving functions if it
decreased the confidentiality problem?

x33 _no don’t know

3. Where is confidentiality on your priority list?

I
‘ high medium low

 

HOSPITAL 013
489 Beds, Public Facility

I-queiEsiatinamm

1. What information is abstracted from the medical record and on

computer?

:Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

 

admission dates.

 

a. How is this data used?

Administration . Research

 

Physician use

 

 

be 'W.' “”7,

Administhato'rs - -- ~' - Research

 

Physicians Allied health professionals.

 

Cr How it this date obtained? Printout or photocopy?

Standard response: Data obtained directly from the medical chart; the

 

chart is coded. Utilize photocopy.

. e - O O

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file? '

Standard response: The chart is first coded then input onto computer.

AL

Those individuals (transcriptionists) who worked with the manual‘record‘

 

are now authorized to add/change, delete information per medical record

 

department personnel.

 

 

 

1223 _i.--_-”,

a. How has this changed with the computer?

Standard response: No change; same as with the manual record.

 

 

.3. Who renders this policy?

 

Standard response: Medical record department personnel.

a. Has this policy changed with automation?

 

No change.

b. if yes, how?

 

A. How long have your medical abstracts been on computer?

Since 1978 °

 

la assesséfissucitx '

1. Where is the computer facility housed?

Outside the medical record department

 

'a. Is it a limited access area?

VII e

 

2. What hardware is used?

IBM

 

3. What software is used?

Dynamic Control out of Florida

 

 

224

a. where was it bought?

Through the hardware company, IBM

 

b. what does it do (any restrictions?)

Set up for medical abstracting of information from patient chart.

 

 

4. Is'your system-a private inrhouse system or is there.outside
access? "

Standard response: Private in-house.

 

‘—

5. Are dumb terminals used“or-p.c.’s? 1 '

Personal computers

 

a. how many terminals are there?

Eight

 

6. How were the employees trained?

By the software company and the medical record personnel

 

7. Who has access to the system?

Standard response: Transcriptionists and CEO’s in the department.

 

8. What are the backup measures?

Nightly back-up onto tape.

 

as. ...- -———.

225

.9. What is the method of storage?

Stored on tape.

 

 

10. Who renders the policy in this area?

The medical record department

 

a. has it changed with automation?

Yes.

b. if yes, how?

Passwords and identification numbers are used in addition to security

 

codes per Job function; “this limits who has access to what.“

I

c. if no, does the old policy suffice; if not, why not?

 

 

 

226

III- Beleess 9i Iniecmstien

1. How are requestsfifec-information handled?

‘Standard response: Copy the hard copy of the medical.record according

 

 

 

to “need" and who wants the information% Generally, only the

- W T
u . 1

physicians ask for the information and they always have full access.

 

“v—
-

 

a. internal requests?

Standard response: These requests go through the director/assistant

 

director of the department and again according to need.

 

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

 

227 '
IV- Esistina sttsm

assessment

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Retrievability of data

w- .-»-.—-- - - ... “...-.~-.-Oe‘--.—.-—o --

 

2. Better monitoring of data

 

 

 

 

EQELQXREI

1. What are the concerns your employees have with the existing
system?

1. Limitations of the software program

 

 

 

 

Euiix enigmatsd sttsm
assessment

1. In order of your highest priority, what are your concerns with
a fully automated system? . ,

1. Adequate training of personnel, “especially with the doctors”

 

2. Doctor cooperation with the new system

 

3. Backup: ”Still need hard copy of everything documented“

T‘

 

O

228 0.." “.1.” --.- ._“.1,

 

Eealaxsa

1. What are the concerns your employees state they may have with a
fully automated record?

1. Not sure

 

 

 

 

 

L Csniidsntisiitx
1. Prompt confidentiality issue it not mentioned by respondent and
' record response. . .

I
- o

: Stated confidentiality is of crctical importancep'"lt should be. based

on security and who needs the_information to,begin with1“neoncerned that

 

'—

‘cqnfidentiality is not-guarded, and believes this-maz-become worse

 

with a fully automated system?

7* w— . v v" w v

 

0
fl

 

 

 

 

2. Would you agree to decreased retrievability of data if it
decreased the confidentiality problem?

x3. no don’t know
3. Where is confidentiality on your priority list?

DiQD ‘medium low

e --.-».o- ————--—--—---~—o~...

HOSPITAL #14
75 Beds, Private Facility .

1. What information is abstracted from the medical record and on
computer? -

Patient age, sex, religious affiliation, patient identification

 

number, diagnosis, procedures, physicians involved, discharge and

 

admission dates.

 

a. How is this data used?

Administration Research

 

Physician use . Billing/DRG’s

 

 

-b. By—whom?

Administrators Research

+ A

Physicians

 

c. How is this data obtained? Printout or'photocopy?

Standard response: Data obtained directly from the medical chart; the

A

chart is coded. Utilize photocopy.

 

2. Do procedures exist concerning who is authorized to add/delete
and/or change information on file?

Standard response: The chart is first coded then input onto computer.

 

Those individuals (transcriptionists) who worked with the manual record

 

are now authorized to add/change, delete information per medical.record

 

r

department personnel.

 

- m . 229

230

i
a. How has this changed with the compute

Standard response: No change; same as wit

 

a. Who renders this policy?

Standard response: Medical record department personnel.

 

a. Has this policy changed with automation?

No change.

 

b. if yes, how?

 

4. How long have your medical abstracts been on computer?

Since 1985

 

.Ie assessLSssucitx

1. Where is the computer facility housed?

Outside the hospital

 

a. Is it a limited access area?

Yes.

 

2. What hardware is used?

IBM ' -

 

3. What software is used?

PAS PLUS

 

231

a. where was it bought?

From CPHA

—u—_-_—-—-‘-—-—--_-—-‘-——-————_-————--c--—_n---_------—--~—---------_—---—

?)

b. what does it do (any restrictions

Set up for medical abstracting of information from patient chart.

.-“-_‘—_-*n—--—_--———---“——Q-u--—e_——..---—-e————---——_----—__—_~--—-_-———-

4. Is your system a private in-house system or is there outside
”access?

J

Standard response: Private in-house.

5. Are dumb terminals used or p.c.’s?

Dumb terminals

a. how many terminals are there?

Two

 

6. How were the employees trained?

By'the software company

—--—- ————-fl-——‘-———‘-——_-—e“—e——-e_~~——---—

'7. Who has access to the system?

Sitandard response: Transcriptionists and CEO’s in the department.

—=-—-—’-—-—— —_ --‘ ‘-—-“‘—““‘“‘=—_——--.—-—-a—-———

8. What are the backup measures?

Nightly back-up onto a disk

——

233

1. How are requests for information handled?

Standard response: Copy the hard copy of the medical record according

+
1 I —

to "need" and who wants.the information. The same process is used

.... _

as with the manual record.

 

 

a. internal requests?

Standard response: These requests go through the director/assistant

director of the department and again according to need.

 

 

b. external requests?

Standard response: This is state-mandated as to what outside parties

 

have access to this information.

 

 

23g . -.-m_h_.-muu_..-. .._" ,*_
IV- Eaiatina Sxaism

nansasmsns

1. In order of your highest priority, what are your concerns as a
manager with the existing automated record?

1. Problems with the screens and it slows down the work process

1'—

 

 

 

 

 

592192221

1. what are the concerns your employees have with the existing
system?

1. Time lapse between screens

 

 

 

 

 

Eallx enigmassn Exszsm

nansnsmsnt .

1. In order of your highest priority, what are your concerns with
a {ully automated system?

1. Adequate training: "Information is only as good as the people who

 

input the inéormation."

 

2. Doctor cooperation with the change-over to a fully automated

system; getting adequate time to train them on the system

 

 

235

Emelsxss

1. What are the concerns your employees state they may have with a
fully automated record?

1. No real change/concerns known, other than time lapse between screens

 

 

 

 

 

Confidentiality

 

l. Prompt confidentiality issue if not mentioned by respondent and
record response.

_Agresd confidentiality is of great importance: VefiV“cEncerned

gwith getting validfraliabfe eampaear venibr where the software is

MAL .; .A ‘ -
w.

configured to insure‘confidsntiality. Stated the’fmportance of

v

anticipating problems with confidentiality once there is a fully.-

 

automated system. Says confidéntiality is of the-fiighest importance '

 

regardless of any ”economic, time-saving devices-“

 

I

 

 

 

 

2. Would you agree to a decrease in time-saving measures if it
decreased the confidentiality problem?

1;; no don’t know

 

3. Where is confidentiality on your priority list?

high medium low

.ul

3 13 L IOGRAPHY

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