As computer printouts replace handwritten and typewritten information in a Medical Records department, it becomes more advantageous for the Registered Records Administrator (RRA) to learn how to interact with a computer terminal. Computer applications in the Medical Records field increase the availability and accessibility of patient information. The Medical Records System discussed in this paper has been adapted by the Medical Records department of the College of Health Sciences of the University of Central Florida as a tool for demonstrating the relationship between the computer and the successful management of medical records. This system will provide hands on experience to all medical records students. It has the capability of adding, deleting or changing the medical records of patients on the Master Patient Index and the Patient Master File. Statistics are calculated and reports are generated monthly or on request for areas of particular interest, such as Payment Source, Discharge Analysis, and Utilization Review. These reports help analyze the effectiveness of specific treatment and the flow rate of patients. As improvements become necessary, the system will be modified to reflect any new requirements in the medical records field.

Since the early 20th century, the view has developed that high quality health care can be delivered only when all the pertinent data about the health of a patient is available to the clinician. Various types of health records have emerged to serve the needs of healthcare providers and more recently, patients or consumers. These health records include, but are not limited to, Personal Health Records, Electronic Heath Records, Electronic Medical Records and Payer-Based Health Records. Payer-Based Health Records emerged to serve the needs of medical aids or health care plans. Electronic Medical Records and Electronic Health Records were targeted at the healthcare provider market, whereas a gap developed in the patient market. Personal Health Records were developed to address the patient market, but adoption was slow at first. The success of online social networking reignited the flame that Personal Health Records needed and online consumer-based Personal Health Records were developed. Despite all the various types of health records, there still seems to be a lack of meaningful use of personal health records in modern society. The purpose of this dissertation is to propose a framework for Personal Health Records in online social networking, to address the issue of a lack of a central, accessible repository for health records. In order for a Personal Health Record to serve this need it has to be of meaningful use. The capability of a PHR to be of meaningful use is core to this research. In order to determine whether a Personal Health Record is of meaningful use, a tool is developed to evaluate Personal Health Records. This evaluation tool takes into account all the attributes that a Personal Health Record which is of meaningful use should comprise of. Suitable ratings are allocated to enable measuring of each attribute. A model is compiled to facilitate the selection of six Personal Health Records to be evaluated. One of these six Personal Health Records acts as a pilot site to test the evaluation tool in order to determine the tool’s utility and effect improvements. The other five Personal Health Records are then evaluated to measure their adherence to the attributes of meaningful use. These findings, together with a literature study on the various types of health records and the evaluation tool, inform the building blocks used to present the framework. It is hoped that the framework for Personal Health Records in online social networking proposed in this research, may be of benefit to provide clear guidance for the achievement of a central or integrated, accessible repository for health records through the meaningful use of Personal Health Records.

M.Tech. (Radiography) / The Radiology Information System and the Picture Archiving and Communication System have contributed to improved patient care by eradicating delays in the clinical management of patients. This is achieved by permitting access to instantaneous radiology interpretations and secondary consultations; creating a basis for teleradiology and reducing storage costs by replacing conventional archives with cheaper digital storage. However, the former has attributed to the recent rise in confidentiality breaches involving medical data in the United States of America. Yet, reports of this nature remain unknown in the South African context. Breaches by authorised users remain an under investigated issue and continue to threaten the confidentiality of data. This assumption was employed as the conceptual basis for this study while, the Theory of Planned Behaviour was utilised to generate probable causes of deviant behaviour. A sample of health professionals (n=115) and information technologists (n=2) was drawn to collect data. The extent of compliance was expressed as a percentage error of the discrepancy between the observed behaviour and the regulations stipulated by the Health Insurance Portability and Accountability Act. The independent variable (work practices) were categorised into access restriction, intrinsic security measures and the actual breach incidences. The non-parametric Chi-Square test was used to calculate statistical significance the correlational extent of which was determined using the phi coefficient. Both Research Settings indicated poor compliance (percentage errors of 67.3 and 70.37) with the mandated regulations. The study provides insight about the confidentiality status within the South African context. This is the kind of information sought by regulators to aid keep pace with the rapid advances in Information Technology.

Thesis (MTech (Information Technology))--Cape Peninsula University of Technology, 2016. / Access to healthcare is regarded as a basic and essential human right. It is widely known that ICT solutions have potential to improve access to healthcare, reduce healthcare cost, reduce medical errors, and bridge the digital divide between rural and urban healthcare centres. The access to personal healthcare records is, however, an astounding challenge for both patients and healthcare professionals alike, particularly within resource-restricted environments (such as rural communities). Most rural healthcare institutions have limited or non-existent access to electronic patient healthcare records. This study explored the accessibility of personal healthcare records by patients and healthcare professionals within a rural community hospital in the Eastern Cape Province of South Africa. The case study was conducted at the St. Barnabas Hospital with the support and permission from the Faculty of Informatics and Design, Cape Peninsula University of Technology and the Eastern Cape Department of Health. Semi-structured interviews, observations, and interactive co-design sessions and focus groups served as the main data collection methods used to determine the accessibility of personal healthcare records by the relevant stakeholders. The data was qualitatively interpreted using thematic analysis. The study highlighted the various challenges experienced by healthcare professionals and patients, including time-consuming manual processes, lack of infrastructure, illegible hand-written records, missing records and illiteracy. A number of recommendations for improved access to personal healthcare records are discussed. The significance of the study articulates the imperative need for seamless and secure access to personal healthcare records, not only within rural areas but within all communities.

The revolutionary migration within the health care sector towards the digitisation of medical records for convenience or compliance touches on many concerns with respect to ensuring the security of patient personally identifiable information (PII). Foremost of these is that a patient’s right to privacy is not violated. To this end, it is necessary that health care practitioners have a clear understanding of the various constructs of privacy in order to ensure privacy compliance is maintained. This research project focuses on an investigation of privacy from a multidisciplinary philosophical perspective to highlight the constructs of information privacy. These constructs together with a discussion focused on the confidentiality and accessibility of medical records results in the development of an artefact represented in the format of a model. The formulation of the model is accomplished by making use of the Design Science research guidelines for artefact development. Part of the process required that the artefact be refined through the use of an Expert Review Process. This involved an iterative (three phase) process which required (seven) experts from the fields of privacy, information security, and health care to respond to semi-structured questions administered with an interview guide. The data analysis process utilised the ISO/IEC 29100:2011(E) standard on privacy as a means to assign thematic codes to the responses, which were then analysed. The proposed information privacy model was discussed in relation to the compliance requirements of the South African Protection of Personal Information (PoPI) Bill of 2009 and their application in a primary health care facility. The proposed information privacy model provides a holistic view of privacy management that can residually be used to increase awareness associated with the compliance requirements of using patient PII.

The primary purpose of the present study was to determine if information regarding potential parental or legal guardian access to mental health information would deleteriously impact male and female adolescent psychiatric patients' willingness to self-report personal problems and symptoms.

The study sought to investigate the factors influencing the contents of antiretroviral therapy (ART) reports in the Amathole Health District of the Eastern Cape Province. A qualitative and quantitative study was conducted to assess the challenges that inhibit this phenomenon. Structurally, the population consists of Amahlati and Nkonkobe sub-districts. Operational managers, information officers, professional nurses, data capturers, and administration clerks were randomly selected from sixteen facilities. Data collection was done on semi-structured interviews, questionnaires; observations were done using the probability sampling method, and the findings were analysed according to the same technique. The study revealed that the District Health Information System (DHIS) is the universal data management and reporting system which all healthcare and ART facilities are using to manage ART. However, regardless of all these universal arrangements such as the use of the DHIS to aid in reporting, the contents of ART reports from various facilities have not been uniform due to various factors. There is a lack of a reliable network to link DHIS computers across facilities. The shift from paper-based to electronic data management has caused the difficulties in the collating and management of ART data since some facilities are manual paper- based while others are automated using the modern DHIS. Lack of daily capturing and validation is a major challenge across the ART facilities. Further, there are Non-Governmental Organisations(NGOs) such as AFRICARE and the IYDSA that have signed a memorandum of understanding (MOU) with the district to provide a budgetary support for staff training in data management of ART reports in the district. While the NGOs keep on assisting the ART facilities with data management, there is a lack of skills transfer. The district could not account on follow-up of ART patients from one facility to another. This is increasing the number of defaulting in ART patients, thus there is no accurate figures on retention of patients in ART Programme. The officials from ART sites tend to use their own transport to carry data from facilities to the district offices and this resulted in late submission of reports. The study thus recommends that, inter alia, data management and trainings should be done to improve data quality in reporting, a reliable computer network be installed, backed-up and maintained for data and report management in the all healthcare facilities. All the ART sites should adopt and use the automated data management system for universality and eliminating the faults of manual paper data management and reporting. This would ensure that the contents of ART reports are uniform and a true reflection of the situation on the ground towards universal access to ART and healthcare in the Amathole Health District, and South Africa at large.

Senior Health Care System (SHCS) is created for users to enter participants' conditions and store information in a central database. When users are ready for quarterly assessments the system generates a simple summary that can be reviewed, modified, and saved as part of the summary assessments, which are required by Federal and California law.

Indiana University-Purdue University Indianapolis (IUPUI) / Reducing medical error remains in the forefront of healthcare reform. The use of health information technology, specifically the electronic health record (EHR) is one attempt to improve patient safety. The implementation of the EHR in the Emergency Department changes physician workflow, which can have negative, unintended consequences for patient safety. Inaccuracies in clinical documentation can contribute, for example, to medical error during transitions of care. In this quasi-experimental comparison study, we sought to determine whether there is a difference in document quality, error rate, error type, cognitive load and time when Emergency Medicine (EM) residents use paper charts versus the EHR to complete physician documentation of clinical encounters. Simulated patient encounters provided a unique and innovative environment to evaluate EM physician documentation. Analysis focused on examining documentation quality and real-time observation of the simulated encounter. Results demonstrate no change in document quality, no change in cognitive load, and no change in error rate between electronic and paper charts. There was a 46% increase in the time required to complete the charting task when using the EHR. Physician workflow changes from partial documentation during the patient encounter with paper charts to complete documentation after the encounter with electronic charts. Documentation quality overall was poor with an average of 36% of required elements missing which did not improve during residency training. The extra time required for the charting task using the EHR potentially increases patient waiting times as well as clinician dissatisfaction and burnout, yet it has little impact on the quality of physician documentation. Better strategies and support for documentation are needed as providers adopt and use EHR systems to change the practice of medicine.