United General Hospital Case Study – The practice of effective health record management is imperative in any institution offering health services to ensure quality service delivery. All healthcare professionals know that health records are an essential tool that hospitals need to realize their missions and visions.
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- United General’s hospital administrator reviewed the hospital’s policy manual and discovered that it inadequately addresses the area of patient records. The hospital administrator tasks you with reviewing the hospital policy manual and reporting on the thoroughness of its coverage of patient records. After a review of the policy manual, you report that the coverage of patient records is sparse and outdated. The hospital administrator then asks you to update the policy manual.
- Develop a policy manual introduction that includes the following (1–2 pages):
- Write an update to the manual’s introduction, which includes more depth in the area of patient records. As you write this section, describe the purpose of patient record protection and its importance to the organization.
- Include an explanation of the legal requirements for protecting patient health records.
- Because Pete compromised Winnie’s patient records, the hospital administrator tasks you with identifying other potential risks that the hospital and the primary care physicians may need to address to protect patient records.
- Conduct a risk assessment, and write a report that includes the following:
- Identify risks to both electronic and paper patient records and recommend remedies the United General can put in place to protect the records from compromise.
- Create policy statements that comply with HIPAA regulations, addressing access to and disclosure of electronic and paper patient records.
- Describe relevant training topics that will educate the staff on accessing and disclosing patient records.
- Winnie’s lawsuit refers to the violation of patient record protection and privacy regulations, by the United General, as the prime cause of the problem. This has now opened United General to governmental inquiries, as well as to federal lawsuits.
- In 2–3 pages, complete the following:
- Review the requirements of the HIPAA regulations, and identify areas in the case study that breached HIPAA regulations—remembering your analysis of the hospital’s policy manual (the policies applicable to patient record handling and disposal require an update to align with HIPAA regulations).
- Create policy statements that align with HIPAA regulations that address patient healthcare record handling and disposal.
- Describe relevant training topics for staff in order to educate them on the handling and disposal of patient records.
- During Pete’s exit interview, he stated that he did not receive managerial direction or training in regard to accessing computer systems and online patient records. The hospital administrator reviewed the management training manual and found that the area detailing instructions that management needs to give to staff is sparse. The hospital administrator asks that you write a section of the management training manual to provide clear instructions for management oversight in the area of handling and accessing patient records. As part of managerial oversight of hospital staff, access to patient records should be restricted and only available to appropriate staff members. For instance, in this case study, Pete should not have had access to Winnie’s patient record.
- Develop a section of the management training manual that includes the following:
- Write at least four clear instructions for management oversight in the area of handling and accessing patient records.
- Create at least two policy statements for role-based security level access to patient records.
- List at least three methods to set security levels for accessing patient records to support the policy statements.
- Because Pete accessed Winnie’s record using mobile and wireless technology, the United General is concerned about their approach to emerging technology. To deal with this potential threat, the United General brought in a security consultant to assess the hospital’s technology environment. The consultant found that the wireless network is unprotected, allowing for unauthorized access to patient records and hospital personnel records. To address this issue, you are tasked to work with the security consultant to describe the role that emerging technologies played in the “United General Hospital Patient Privacy Case Study” document.
- Develop a report for the security consultant that addresses the following (2–3 pages):
- Evaluate the role that emerging technologies play in access to patient records.
- Create policy statements for the use of wireless technology and access and how emerging and mobile technologies will be introduced.
- Describe relevant training topics for staff in order to introduce emerging technology and educate them regarding the possibilities presented by emerging technology.
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United General Hospital Case Study
The practice of effective health record management is imperative in any institution offering health services to ensure quality service delivery. All healthcare professionals know that health records are an essential tool that hospitals need to realize their missions and visions. As such, health record management has to ensure quality, accessibility, authenticity, and securing of information, whether it is stored in paper or electronic form (Clearwater compliance, 2018). Medical service delivery’s efficiency and effectiveness depend on the professional staff knowledge and the record-keeping processes (WHO, 2018). Suffice it to say that a patient’s record serves several purposes within a hospital environment. First, it is a communication tool within the healthcare organization setup and may serve as a legal document used as evidence in a law court. Besides, the patient record can be used for billing and research purposes. The patient information contained therein has patient identification details like names, contact details, the patient’s medical history, diagnosis, and subsequent treatment. Due to the sensitivity of their contents, hospitals must ensure that they adopt appropriate measures that safeguard the privacy and confidentiality of the patient information contained therein as a breach of these can see the patient and their family seeking legal redress from the healthcare professional involved as well as the healthcare organization itself. To demonstrate this, the paper examines the United General Hospital Patient Case Study where Pete inadvertently released the HIV status of Winnie Noble, the mother of his girlfriend. To achieve the goal, the paper commences a summary of the background to the case study before presenting the salient aspects into five main parts. Part 1 gives a hospital’s policy manual introduction; Part 2 focuses on risk assessment, while Part 3 delves into alignment of the emerging legal issues with regulatory requirements. Next is Part 4, which examines the managerial oversight before exploring emerging technologies’ roles, then ends with a conclusion reviewing the paper’s highlights.
Background to the UGH Case Study –A Summary
United General Hospital is a healthcare facility located in Des Moines, Iowa. It serves the local community’s population so that they do not have to travel to Des Moines for care. The small number of its physicians means that sometimes an intern or nurse does assist the primary care physicians when the physician’s assistant is not available. Among these is Dr. Moore, the mother of one of her patients Winnie Noble whose hospitalization resulted from a drug dealer’s knife attack. Winnie’s daughter Pam has a boyfriend called Pete, who accidentally learned that Winnie tested for HIV. Using his iPad, he managed to connect to the hospital’s wireless network, accessed Dr. Moore’s patient records, reviewed Winnie’s diagnosis, and used his Twitter account to inform Pam about her mother’s (Winnie) condition. Their Twitter followers picked up the tweet masking Winnie’s diagnosis to go viral. Following this, Winnie sued UGH, Dr. Moore, and Pete for privacy invasion, violation of patient record protection under the Health Insurance Portability and Accountability Act (HIPAA), and the ensuing emotional and physical distress. Winnie seeks punitive damages and requests that the Department of Justice and the Center for Medicare and Medicaid Services investigate UGH’s security policy on violation of federal patient privacy regulations where the investigation into the matter is in progress.
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Like many other healthcare facilities, UGH is working towards developing processes and systems bound to ensure it provides control and helps protect security breaches associated with comprised data and patient confidentiality. The need to protect patient data is paramount against the backdrop of mounting challenges as the hospital transitions paper to electronic information sharing and storage. Seh et al. (2020) opine that the number of patients who have experienced data breaches increases with every passing day, necessitating that organizations put even more stringent guidelines and rules for the hospitals. UGH requires incorporating stricter and more insightful guidelines to resolve the increase in numbers of patients who call for updated technology to manage the increasing volumes. The HIPAA of 1996 outlines that a hospital develops regulations that protect patient information privacy. The utilization of modern clinical technology in patient information storage and other health systems has exposed many potential security risks. The security laws required covered individuals to be guaranteed their confidentiality, integrity, and compliance by the organization’s workforce against unauthorized and improper access to their privileged information. As the National Center for Medical Records (2018) notes, HIPAA requirements grant patients fundamental privacy rights. Despite putting the rules and regulations in place, the risk analysis of a manual review of records and access tracking should be implemented as a continuous process (OCR, 2015). Only by doing so will the institution in context follow the HIPAA general rules. Using the recommended basic models can allow reasonable protection as mandated by the statutes.
Having given a brief introduction to the policy manual, Part 2 conducts a risk assessment that identifies both paper and electronic patient records risks. Suffice it to say that healthcare facilities are responsible for identifying potential risks and then implementing assessment measures geared towards protecting patient records. The moment a patient’s records become easily accessible to many individuals, it calls for proper compliance strategies to be imitated. Besides the potential files and other costs associated with compliance, hospitals are duty-bound to suffer the loss of reputation and trust (Ablon et al., 2016). Subsequently, the hospitals have to control the information access and offer best practice techniques like ensuring access to the same password. It is essential to consider that information access breaches include but are not limited to how they are created, stored, maintained, and exchanged. The handling of confidential patient information exposes the staffer to the risk of having unauthorized access and potential malpractice liability, like errors emanating from inaccurate data entry. Through sufficient training, the hospital can enforce the protection of patient data guidelines. This calls for a multimodal approach strategy leading to the integration of staff education and physical security ad improvement.
The HIPAA regulations capture, amongst other things, the permanent destruction of patient records when they are no longer required. UGH can protect the network by segregation, encrypt portable devices, and securing wireless networks, amongst other measures, to oversee patient information protection. The remedial measures would then reinforce the significance of patient confidentiality, thereby ensuring the hospital does not encounter unnecessary legal liabilities. The UGH policy statement is in line with HIPAA regulations concerning access ad disclosure of paper ad electronic patient records.
UGH should coordinate the IT security program and focus on employee education and secure patient information through passwords to optimize security measures. Additionally, the hospital should implement physical security controls where files and equipment are locked safely and encrypt all patient data devices. Authorized parties need to understand and stick to the requirement that calls for deleting unnecessary data, compromising patient confidentiality if not properly destroyed. Lastly, the organization should ensure that a plan has been put in place for rapid response if a security breach materializes. Comprehensive understanding of patient confidentiality and respect for all individuals’ privacy should comprise the foundation inculcated in all individuals. To ensure that appropriate standards are met, training seminars should be conducted focusing on general confidentiality, patient rights, management of passwords, virus protection, and federal and state laws, to mention but a few. The training schedules should capture the implementation guidelines and software training sessions.
The lawsuit filed by Winnie seeks to address the violation of patient data protection and the HIPAA regulations, which should form the basis of how all healthcare organizations handle patient information. The first violation of both the hospital’s policy and HIPAA regulations is that the patient information was not used for medical purposes. Those who gained access to it had not been authorized by the patient Winnie herself. Another violation was that the patient’s confidential data had not been stored by the hospital and the EMR system, where they also did not have password protection. Failing to secure the access of medical charts and the absence of data encryption installation within the health system’s software violated HIPAA regulations that require patient confidentiality to be met at all levels. For example, the Wi-Fi was readily available to any individual as Pete could connect. Due to this paper’s scope, the last of the violations to be explored was that HIPAA rules and regulations set it that the organization and its staff should reach out to the patient and notify them once a security breach has occurred. In this criminal case, as an intern, Pete was fully aware of his actions yet proceeded to reveal the patient’s data on social media. This implies that charges should be pressed upon him since the American Medical Association mentions of individuals who willfully and knowingly disclose confidential health information be held liable According to the AMA (2018), a fine of up to $ 50 000 and an imprisonment of 12 months also points to the need for a Federal investigation and severe legal sanctions be imposed. Besides legally sanctioning Pete, the hospital also has to align its policies to the HIPAA laws. The hospital has to limit medical charts, lab, and diagnostic results to enhance information security. UGH has also initiated higher security measures by implementing electronic patient health information’s final disposition. As the Office for Civil Rights (2015) notes, the facility must integrate an oversight system to manage the records management team. In a nutshell, all these policy measures, once fully implemented, will be under the direct coordination of the executive team to offer a safe organization where patient satisfaction is expected. This
Management oversight plays a vital role in any hospital’s operations and serves as the cornerstone of all regulations and protocol implementation. It embraces the goals that provide guidance and effective monitoring of the health care system. Therefore, for UGH to attain patient safety management and ensure information security and confidentiality, several measures have targeted the management of staff as a way of helping in the coordination of roles and strict adherence to the guidelines that dictate access to and handling of patient information. The executive management team issues instructions about oversight on accessing and handling patient records. Top among these instructions are setting and guiding control policies at the internal level, coordinating and implementing strategies that the hospital’s board of directors has set besides ensuring effective communication in training and organization or regulations. Therefore, the policy statement focuses on developing duties based on one’s role and the implementation of security levels of how confidential patient data is accessed. To maintain high security during access of patient data within UGH, the recommended protocol to follow entails having the BOD provide guidance and oversight for senior-level executives by outlining the policies and ensuring the newly developed structure’s approval. The managerial team is responsible for task delegation at the staff level while the executive team coordinates its execution. Additionally, individual managers are responsible for making follow-ups with direct reports to ensure strict adherence to the regulations, meeting all protocols, and keeping direct logs as stipulated by the respective state guidelines. Doing so would close the gap in understanding protocols where every person that signs onto the hospital’s team in whatever way is coordinated through the managerial team where after the requisite training, commensurate access is required for completion of specific patient care tasks.
Usually, several methods are needed to implement different security levels. Having a strong internal system ensures no errors pass without detection. Both incentive and compensation methods should be used in varying degrees to inspire the workforce to reach the set goals. Ethical values reinforcement is also needed from time to time within the hospital to refresh its ideals (Ozair et al., 2015). Be that as it may, the facility should never relent in averting and dealing with criminal acts that touch on patient health information disclosure. UGH monitors all systems and collaborates with other hospital teams to ensure that only the safest practice and maintenance of trust and good reputation are advanced within this hospital at all times.
Healthcare professionals of the 21st century have to remember that they are working during the digital information age where digital communications and information resources cut across almost every aspect of their patients. Therefore an evaluation of the role that emerging technologies play in accessing patient records is required. Alotaibi (2017) notes that health information technology has presented numerous opportunities to improve and transform healthcare by reducing human errors, facilitating care coordination, and improving clinical outcomes. This is because they allow for sharing required patient information in real-time. The flip side is that people with criminal intent or those who unintentionally release privileged health in is secure information also have access to these data. For example, a patient electronic portal is a secure online application that accords patients the chance to access their personal health information and 2-way electronic communication with their care provider using a computer or mobile device. Others include electronic sign-out and handover communication. For these and other reasons, if the hospital’s health information system is not secure, securing breaches can occur.
UGH, policy statements for the use of wireless technology and access will include the introduction of radiofrequency communications technology as it offers a seamless communication highway linking all stakeholders (Ahmed et al., 2020). Similarly, visible light communication has emerged as an effective way of transmitting information wirelessly and will also be tapped. A hospital environment consists of people (like patients, medical staff, visitors), process (like a diagnosis to treatment), technology, and premises. Another policy statement on the introduction of emerging technologies will be creating a clear division between inpatient and outpatient healthcare, offer 24/7 reliable monitoring in telemedicine (remote healthcare and provide real-time monitoring and data collection of management processes. The topics to be taught include data systems, data privacy, and information security in emerging technologies. Information security threats and how to address them.
In conclusion, this essay has determined that patient privacy is the right and desire of a person to regulate personal health information disclosure. Next is confidentiality. The release of information to the caregiver is controlled under an agreement that curtails the extent and conditions to which the personal health information can be used or shared with others. Finally, patient data security has been established to collect policies, procedures, and safeguards whose successful implementation as envisaged under HIPAA is bound to maintain and promote the integrity and accessibility of patient health information. Every hospital UGH included must recognize the risks of disclosing health care information where emerging technologies are beneficial but only if measures are taken to secure and control patient health information access.
Ablon, L., Heaton, P., Lavery, D. C., & Romanosky, S. (2016). Consumer attitudes toward data breach notifications and loss of personal information. Rand Corporation.
Ahmed, I., Karvonen, H., Kumpuniemi, T., & Katz, M. (2020). Wireless communications for the future hospital: requirements, challenges, and solutions. International Journal of Wireless Information Networks, 27(1), 4-17.
Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi medical journal, 38(12), 1173.
AMA. (2018). American Medical Association. HIPAA Violations & Enforcement (6). Retrieved from: https://www.ama-assn.org/practice-management/hipaa-violations-enforcement
Clearwater Compliance. (2018). Problems with Paper: Medical Record Mistakes Put Patients at Risk. (3, 5). Retrieved from: https://clearwatercompliance.com/blog/problems-paper-medical-record-mistakes-put-patients-risk/
National Center for Medical Records. (2018). Medical Records. HIPAA Requirements (2). Retrieved from: https://www.medicalrecords.com/physicians/hipaa-and-medical-records
OCR. (2015). Health Information Privacy. What do the HIPAA Privacy and Security Rules require covered entities when they dispose of protected health information? (2)(4). retrieved from: https://www.hhs.gov/hipaa/for-professionals/faq/575/what-does-hipaa-require-of-covered-entities-when-they-dispose-information/index.html
Ozair, F. F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical issues in electronic health records: A general overview. Perspectives in clinical research, 6(2), 73.
Seh, A. H., Zarour, M., Alenezi, M., Sarkar, A. K., Agrawal, A., Kumar, R., & Khan, R. A. (2020, June). Healthcare data breaches: Insights and implications. In Healthcare (Vol. 8, No. 2, p. 133). Multidisciplinary Digital Publishing Institute.
World Health Organization. (2018). Delivering Quality Health Services: A Global Imperative. OECD Publishing.
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