Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Privacy, Confidentiality, and Security
Lecture:Tools for protecting privacy and confidentiality
Slide content:Security for Paper Records Is a Significant Problem Difficult to audit trail of paper chart Fax machines, scanners are easily accessible Records frequently copied for many reasons New providers, insurance purposes Records abstracted for variety of purposes Research Quality assurance Insurance fraud Medical Information Bureau ( Rothfeder , 1992) 6
Slide notes:Its important to note that even though concerns about privacy and security are heightened with electronic systems, paper records have their own set of privacy and security problems. In fact, some have argued that paper medical records may be more prone than electronic records to breaches of security and disclosure. Unlike electronic records, it is very difficult to audit the trail of a paper chart. Even with paper-based tracking documents, it is not clear exactly where the chart goes and who has looked at it. Electronic information systems are able to provide a detailed audit trail as a background process that identifies everyone who logs into the software application and tracks their specific system activities with a date and time stamp. There are also issues with fax machines and scanners. Even in this electronic era, many people still rely on fax machines and scanners to move information. When the document comes out of fax machines, anyone can view the paper, and it is difficult to track where the paper goes. Also, data stored in fax machines and scanners can easily be accessed. Records also continue to be photocopied. We photocopy for many reasons: the patient goes to a new provider, the insurance company needs to have documentation that a specific procedure was done or referral was made, and records get abstracted by individual people. After copying, the paper copies may be scanned into information systems. More advanced systems allow scanning of documents directly into the software application. Whether they are paper or electronic, records are also copied for research or quality assurance purposes. Most health care insurers belong to the Medical Information Bureau, which monitors for insurance fraud and other insurance-related concerns. The Medical Information Bureau has developed a huge database of individuals health care claims, looking very properly for health insurance fraud but also collecting quite a bit of information on individuals personal health. 6