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TopIn the past decade clinical records have been greatly transformed. Increasing use of health information technology (the Electronic Health Record and its associated tools) has had a dramatic effect, not only on how medicine is practised, but also on how doctors and patients access medical information. In particular the proliferation of health information available on the internet has been growing exponentially. Unfortunately quality is variable and the information is not always beneficial for health service users seeking help.
On the provider side, the aims of electronic health records (EHRs) are to provide a single repository for several different types of records, to increase accessibility, but also to improve security for such a personal document. In sites which still use paper records the old problems associated with this format persist: missing files, illegibility, difficulty locating entries, and large cumbersome charts. With a paper file, simultaneous use is impossible. Security is dependent on the location of the chart, with some ward areas having an unlocked storage trolley lying in the corridor, easily accessible. Health professionals sometimes leave charts on beds or desks, or allow private information to be left visible. Tracking who has viewed what pieces of information is impossible. And of course, viewing can only take place wherever the chart is located.
The ongoing drive to make all records electronic has gained momentum because of several factors. Benefits have been shown to patient safety, clinical outcomes and length of stay (Kuperman & Gibson, 2003). Prescription and dispensing errors have been reduced (Kaushal, 2003). The return on investment can be such that systems pay for themselves as health facilities become more efficient (Wang et al., 2003). The ability to instantly share records, and gain specialist opinion by telemedicine has changed medical practice (Scalvini, Rivadossi, Comini, Muiesan, & Glisenti, 2011). Coupled with a growing recognition that the patient or service user should be at the centre of the process, there is now a real possibility that EHRs can empower consumers of healthcare.
From a rights perspective such a move is long overdue. Freeing personal health information from providers by improving patient access encourages transparency and should increase autonomy and shared decision-making. Health information technology has been the catalyst to this significant shift in medical perspective. It demonstrates that technology triggers socio-technical change. What is clear is that the age of medical paternalism is over. The internet has helped to set information free, and healthcare is not immune from this process. But as well as strengthening and offering opportunities to human rights, there is the potential for inherent weakness in the system we are still building. A sound legal framework is a necessity to protect our health information.