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HIMSS' Electronic Medical Record Adoption Model is the most widely used assessment of digital excellence in healthcare internationally. [5] [6] The model goes from Stage 0 to Stage 7 [7] [6] and describes the adoption and use of electronic health records by hospitals.
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
Traditionally focused mainly on hospitals and paper medical records, the field presently covers all health information technology systems, including electronic health records, clinical decision support systems, and so on, for all segments of health care. As of 2013, the association has more than 71,000 members in four membership classifications.
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
One of the federal laws enacted to safeguard patient's health information (medical record, billing information, treatment plan, etc.) and to guarantee patient's privacy is the Health Insurance Portability and Accountability Act of 1996 or HIPAA. [106] HIPAA gives patients the autonomy and control over their own health records. [106]
An Epic electronic health record system costing £200 million was installed at Cambridge University Hospitals NHS Foundation Trust in October 2014, the first installation of an Epic system in the UK. [36] [37] After 2.1 million records were transferred to Epic systems, it developed serious problems and the system became unstable. [38]