It is imperative that clinicians know the rights and responsibilities of using electronic health records.
Despite commitments to electronic health initiatives by governments in Australia, Belgium, Canada, Denmark, the United Kingdom and the United States over the past decade, clinicians experience challenges in adoption and use. Clinicians may still be unsure that the benefits of these systems outweigh the time and resources required to maintain and update electronic records. To overcome these challenges, two US researchers identified 10 topics that they propose as professional "rights," along with corresponding responsibilities that if addressed, may help overcome the electronic health record use challenges facing clinicians.
"The 10 key issues discussed here form a set of features, functions and user privileges that clinician users require to deliver high-quality, safe and effective care," write Dr. Dean Sittig, University of Texas Health Sciences Center at Houston and Dr. Hardeep Singh, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine.
The "rights" for clinicians include the following:
- Uninterrupted access to electronic health records
- Ability to view all clinical information relating to their patients
- Succinct summaries of patient health histories, including medical problems, medications, lab results and other information
- Ability to override computer-generated clinical interventions
- Clear, evidence-based rational for computer-generated clinical alerts or recommendations
- Reliable performance measurement
- Safe electronic health records
- Training and assistance in all features of electronic health records
- Safe, effective usable electronic health records that are compatible with actual clinical practice
- Electronic systems that support communication and teamwork in the real world
While these topics are proposed as "rights" for clinicians who are expected to adopt and use an electronic health system, the clinician also has a set of responsibilities to ensure safe, efficient and effective use of the electronic health record.
"Addressing these rights and responsibilities comprehensively will be challenging but can make the care delivered through the electronic health records-based work system safer and more efficient," conclude the authors.