Electronic medical records, as the name suggests, are patient medical records stored in digital format, replacing the traditional paper-based record-keeping method.
Traditional paper medical records not only contain records of a patient's medical condition but are also legally binding documents. Therefore, after completing a paper medical record, medical personnel must sign and stamp it to take responsibility.
When medical records are digitized, the traditional method of signing and stamping is no longer feasible. Medical personnel must use electronic signatures to identify themselves as the authors of the electronic medical records, and encrypt the records to protect their integrity and prevent tampering. Currently, the most commonly used signing tool in Taiwan is the healthcare professional IC card. After a digital medical record is signed with an IC card, the document becomes a complete electronic medical record.
After the Electronic Signatures Act was passed in Taiwan, the Ministry of Health and Welfare began promoting the adoption of electronic medical records at hospitals. Our hospital received approval from the Kaohsiung City Health Bureau to implement electronic medical records in December 2009. Currently, our hospital has implemented electronic medical records for "Digital Signature of Imaging Reports," and we aim to become a fully electronic medical records hospital in alignment with the Ministry's policies.
As electronic medical records are gradually implemented, in addition to the benefits they provide, many people are concerned about how their personal health information will be protected. In fact, the Ministry of Health and Welfare has considered this issue while promoting electronic medical records. Privacy protection measures are included in the Personal Data Protection Act and related electronic medical records regulations, which provide detailed safeguards to protect personal privacy.
Our hospital has established an Electronic Medical Records Promotion Committee in accordance with relevant regulations and has implemented strict personal privacy protection mechanisms. In November 2010, our hospital also underwent an electronic medical records inspection conducted by the Taiwan Hospital Association on behalf of the Ministry.
The following are several important measures for the protection of patient privacy:
1. International security certification: Our hospital has established comprehensive construction and monitoring standard operating procedures for the computer room and IT infrastructure that store electronic medical records, and has passed the ISO-27001 information security management international certification in October 2010.
2. Patient consent: With the patient's consent, the patient's National Health Insurance IC card and consent form, together with the attending physician's healthcare professional card, are required to perform inter-hospital electronic medical records exchange.
3. Active access control: Medical records with high sensitivity are regulated under strict review procedures before they can be accessed. Additionally, self-pay items are not subject to inter-hospital exchange, thereby protecting personal privacy.
4. Passive monitoring: For all users of electronic medical records, any additions, deletions, modifications, or reviews of electronic medical records are logged, and original versions before modification are preserved for tracking purposes.
The electronic medical record services currently provided to our patients are as follows:
- Electronic medical records copy application: Within the scope of our hospital's current electronic medical records implementation, you may apply for a printed copy of your electronic medical records at our hospital.
The core value of electronic medical records — "returning medical record ownership to patients" — is to provide patients with better quality healthcare services. With transparent electronic medical record information, patients can, in consultation with their physicians, keep track of their own and their family's health status, thereby truly enjoying appropriate, high-quality healthcare services.
