Electronic Health Records: Privacy, Confidentiality, and Security

Abstract

To understand the complexities of the emerging electronic health record system, it is helpful to know what the health information system has been, is now, and needs to become. The medical record, either paper-based or electronic, is a communication tool that supports clinical decision making, coordination of services, evaluation of the quality and efficacy of care, research, legal protection, education, and accreditation and regulatory processes. It is the business record of the health care system, documented in the normal course of its activities. The documentation must be authenticated and, if it is handwritten, the entries must be legible.