Legal, regulatory, and ethical considerations

Junior (College 3rd year) ・Healthcare&Medicine ・APA ・3 Sources

The UMUC Family clinic objectives are to progress its communication with nursing homes and pharmacies. Elevating communication with the nursing homes will rise patient volume and increase the profit of the hospital. Moreover, Communication with the nursing homes will not only improve the quality of care being offered to the admitted patients but also the discharged patients from the clinic. The kind of communication Dr Martin will have to the nursing homes include, release planning, nursing homes management, admission coordination, and patients follow up visits. Likewise, communication with pharmacies will entail medical orders, top-up orders, and verification of medication records.

Data and data flow

There are several elements of data that the clinic has to share with each external organisation and they comprise of the following; Diagnostic Reports: The data element comprises of lab tests, x-rays, cardiology tests, among other tests that can be requested by the doctor. The received reports are used during transfer of records in and out of Dr Martin’s Family Clinic. Covering physicians at the nursing homes and the hospital review diagnostic results that are given together with patients’ medical records to assess what kind of treatment to offer the patients (Mead, 2006). The diagnostic tests help nursing homes provide quality care, and it also helps pharmacies to trail diagnostic tests and prevent or minimise the need for unnecessary medication. Medication List or Medication Reconciliation: A comprehensive medication report is a vital data element that provides specifications on the name of drugs, when it was started and stopped, dosage, pharmacy name, medication observance and frequency at which it was administered. The data element will be encompassed in medical record updates, transfers in and out of the UMUC Family clinic as well as the nursing homes and pharmacy (Mead, 2006). Medication reconciliation is conducted during admittance and relocations in and out of facilities to ensure an updated list and that patients are receiving the correct medications. Allergies: This data element is required to alert professionals of any adverse reactions about the patient’s present or previous medical history. The information is needed on every medical document and will be transferred before admission and discharge to and from the nursing homes and the clinic. Also, the information is essential to pharmacy and prescription orders to eliminate medical errors as well as incorrect drug reactions. Past Medical History: The past medical history data element is as well necessary for information that is shared within and without the clinic and nursing homes. Such data is significant to the clinic and the nursing homes especially during the transfer and admission of patients in both organisations (Mead, 2006). Nevertheless, the information is also used in patient education, and in pharmacy for purposes of safety contrivances. Physician Progress Notes: Likewise, this data element is vital for the UMUC family clinic and the outside organisations as it shows the patient progress and treatment. UMUC Family Clinic has the responsibility of sharing progress notes with nursing homes to keep covering physicians and line physicians posted about the physical examinations and course of treatment of the patients (Mead, 2006). The nursing homes also, have to share progress notes of patients they have on board with the clinic. Patient Demographics: This includes full names, gender, Date of birth, patient identifier and current address of patients. These facts are required in identifying and following up on Dr Martin’s patients. Each patient information should be correct and clear to avoid any medical errors and improper billing processes. Moreso, such info has to be shared with the nursing homes to admit patients.

Data Interchange Standards

UMUC Family clinic has to apply several standards especially when they are sharing vital information about their patients. Electronic Health Record (EHR) would apply to the data that is exchanged with each organisation. It is an interchange standard that is a patient-centered record, and different health institutions can use to share patients information when and where it is needed. It needs to be created and managed by groups that want to share medical information on patients. It is important because, all the data on patient’s health can be shared between UMUC Family clinic and nursing homes (Learn EHR Basics | Providers & Professionals |, 2017). It has data on patient’s medication, allergies, diagnosis, immunisation dates among other essential information. Another standard that can be put to use is Health Level 7 (HL7) which is a combination of international standards. It incorporates standard messaging protocols because all health care providers have diverse systems for unique aspects of services. HL7 provides the outline for give-and-take, incorporation, sharing and recovery of electronic health information (HL7 Overview - A Comprehensive Guide to HL7, 2017). Therefore, the clinic will be able to be linked to nursing homes through HL7 and relevant information on patients will be shared. Pharmacies can also use such connection to dispense medication correctly.

Legal, Regulatory, and Ethical Considerations

Dr Martin needs to observe regulatory and ethical requirements when employing the data exchange. HIPAA is essential for all healthcare workers, and it is for them to maintain and comply with it legally. The regulation guards privacy of patients health information. The Electronic Data Interchange rule (EDI) is technical, and it explicitly defines the diverse types of transactions that are contained under HIPAA and provides the meticulous format for every transaction record (Ranjbar & Emami, 2015). UMUC Family Clinic should familiarise itself with the EDI rule as well as use it in their practices when exchanging their patient’s information. Data erroneousness is of ethical considerations. Integrity assures data is precise and has not been altered. There are apprehensions concerning the accuracy and consistency of data going into the electronic record. Inaccurate depiction of the patient's current condition and treatment happens because of indecorous application of options like copy and paste (Ranjbar & Emami, 2015). Also, medical identity theft is an ethical consideration. When inaccurate information is fed into the records of patients, insurance institutions are forced to bill for services that have not been provided and as a result future treatments will be jeopardised.


UMUC Family clinic can collaborate with both the nursing homes and the pharmacy in the efforts of giving its services to patients. Data elements that can be shared among these organisation are diagnostic reports, medication lists, allergies, past medical history, physician progress notes and patient demographics. The clinic has to consider both EHR and HL7 interchange standards when sharing its patients’ information. Also, various legal, regulations such as HIPAA and EDI rules should be observed. Ethical considerations the clinic should check are data erroneousness and medical identity theft.


HL7 Overview- A Comprehensive Guide to HL7. (2017). Healthcare Integration Blog - iNTERFACEWARE Inc. Retrieved 16 July 2017, from Learn EHR Basics | Providers &amp

Professionals | (2017). Retrieved 15 July 2017, from Mead, C. N. (2006). Data interchange standards in healthcare it-computable semantic Interoperability: Now possible but still difficult. Do we need a better mousetrap?. Journal of Healthcare Information Management, 20(1), 71.

Ranjbar, H., & Emami Zeydi, A. (2015). Patient Safety. Journal Of Patient Safety, 1.

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