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Introduction - Addressing Documentation Issues and Security Risks in Electronic Medical Records Assignment Sample

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Hello everyone, today I am going to discuss the issues in Electronic Medical Record (EMR) documentation and changes that are required to mitigate those issues for healthcare quality improvement. EMR documentation is considered as the communication tool that is used by healthcare providers to document patients' data so that it can be easily accessible and available to them while providing quality healthcare. However, several issues I have identified while implementing EMR systems include security risks from hackers, data blockage due to poor design, lack of training among staff to properly use electronic documentation, and poor typing skills that slow down documentation (Rosario, 2019). I found that these issues are becoming serious day-by-day and increasing workflow interruption and productivity losses in quality healthcare.

Change requirement in identified healthcare issue

Considering the issues identified in EMR, I want to draw your attention to several key takeaways that healthcare providers can follow while switching from paper documentation to electronic documentation. Here, I want to first mention the importance of creating a safeguard against data hackers while using Smart Devices, Cloud Services, Information Systems, and the Internet of Medical Things in the medical industry. I also want to highlight the reason behind choosing this change requirement in which I need to mention individuals that were affected by healthcare data breaches between 2009 to 2019 that count at 249.09 million (among which 157.40 million were affected in the last five years) (Seh et al. 2020). Furthermore, I think the staff of the healthcare industry need to train about using electronic devices before converting to electronic documentation. Besides that, sometimes it becomes difficult for the nurses and doctors to type patient information over EMR. Hence, speech recognition should be present in EMR to speed up the documentation process. The designing of the interface for documentation needs to be changed and developed by professionals so that data blockade and slow data input can be changed efficiently.

Relevance of the issue to an existing practice priority in New South Wales, Australia

While searching about EMR as an existing practice in South Wales, I found that the country has been using this practice for over a decade. However, no effective benefit of using this has been found so far. It has been found that as in EMR patient information is shared among multiple healthcare professionals, therefore security issues have become one of the main concerns of EMR in Australia (Liu et al. 2020). HealthLink in Australia needs to introduce web-based solutions and privacy measurements to mitigate security issues in using EMR documentation.

Part 2: Model for improvement

Model for Quality Improvement

In order to improve quality healthcare and mitigate the issues the acts that will be addressed by me are strengthening the security system, allocating proper training to the medical staff, and properly designing the interface. Using lean principles, I found that it is the responsibility of healthcare professionals to provide appropriate services to the patients and mitigate all the issues, which create barriers in the context of healthcare effectiveness. It has been found that changing several aspects related to electronic documentation such as detecting office computer skills, recruiting staffs who have high computer literacy and active learning skills is important for delivering quality healthcare (Tai-Seale et al. 2017). Nevertheless, it is also important to allocate continuous improvement until the ultimate goal has been achieved. Hence, I think studying the organisations, which have already implemented EMR documentation successfully, would be beneficial.

Designing aim

(i) I am trying to achieve information about the issues and changes that are required in EMR documentation

(ii) I want to achieve the ultimate success that the changes can make in providing quality healthcare by using EMR

(iii) I want to achieve it within 3 months

(iv) The patients that we serve will benefit from it

The justification behind the change for improvement

It has been found that creating a safeguard against data criminals such as using data access control and firewalls helps in mitigating the issues in EMR. Access control benefits in restricting everyone to use patient data except healthcare providers who required patient health data for their job. Besides that, encryption to the data at transit as well data at rest is a helpful implementation that makes it difficult for the hackers to gain patient data even if they have access. Restriction in using personal mobile devices to gather patient information is also a key takeaway to avoid issues in EMR.

Ways to address aims

First aim will be addressed by gathering information from the internet and informing my fellow professionals about it. I will describe the changes that have been followed by the healthcare industry to successfully use EMR to describe the second aim. For the third aim, I am going to work hard in enforcing identified changes and for the fourth aim, I will take care of the patients along with other nurses and healthcare providers to implement quality healthcare.

Part 3: Recommendations

Description of the process to ensure continuous improvement

In order to achieve the change requirements, a continuous improvement process needs to be recommended that includes strategies for change management, study about it, and its application. It would be recommended to plan strategies like using strong passwords, never stopping educating staff about electronic documentation, regularly updating software, introducing subnetworks for different users. After planning those strategies the healthcare providers can collect data about data breaches that have happened to the medical industry and what steps they have followed to encrypt their patient's health information. Next, the outcome of the following steps should be studied and at last, it will be recommended to act on those steps sincerely.


After considering all the above sections, I want to tell my fellow workers to be responsible for patient data and do everything possible from their side to avoid issues in electronic documentation. The main issue and change requirement area that I have identified is data security issues in ERM documentation that is a key aspect in allocating quality service to the patients and avoiding ethical issues in the healthcare profession.

Executive summary

High-quality healthcare to the patients in healthcare organisations significantly depends upon accurate electronic documentation. This report aims to identify the strategy that I followed as an authentic leader and change management agent to address the challenges to my co-workers about Electronic Medical Record (EMR) documentation. It has been found that digital literacy is an important factor among healthcare providers to manage quality healthcare through EMR.


Appropriate medical documentation of the patient is significant to help the healthcare provider to diagnose patients as per their needs and requirements with the highest ability. This report is going to describe the personal strategy that I will use to mitigate the challenges in Electronic Medical Records (ERM) documentation. Continuous improvement required in working culture, building a professional team, appropriate leadership would be briefly discussed in this report.

Identification of the strategy to raise awareness about the issue

Correlation between strategy and identified issue

I found that healthcare data breaches have significantly increased with time and in 2020, the number of data breaches per day counts at 642. Therefore, as an authentic leader, I want to raise awareness about the issue of using EMR among the registered nurses and interprofessional by following the strategy of educating them about computer use in electronic documentation. I know that change starts from ownself, therefore I will always be updated with information related to ERM and encourage my fellow staff to be more open and communicate if any problem occurs. I found that about 64% of the data breaches in the healthcare industry occur due to the unawareness among staff about cybersecurity. Furthermore, half of the healthcare professionals lack proper cybersecurity training before working in electronic documentation of patients and less than one-third of healthcare providers can define the national healthcare standards and federal law imposed by the government, which resulted in creating challenges in ERM.

Strategy implementation approach

I am going to first discuss the chosen strategy with the key stakeholders and staff present in my organisation. After that, I will describe the key performance indicators such as better documentation of the patient’s data, secure data from computer criminals, and increment in computer literacy among healthcare professionals. All the individuals and team members of the healthcare organisation will follow this strategy in order to deliver understanding about the consequences of patients’ data theft. In this context, self-awareness about dealing with such issues and avoiding such issues in further happening will be appropriate. I would like to address the importance of creating sub networks while discussing the challenges in the issue. While EMR documentation several sub networks can be created for different users such as visitors, patients, medical devices, and personnel. For example, I want to mention that public wifi access can be provided to the visitors, which is different from the internet connection that is used to store patient health information.

Chosen strategy and authentic leadership

Authentic leadership refers to providing essential support to the subordinates, encouraging them to be more open, and allowing success to the organisation (Alvesson and Einola, 2019). Based on this I can say that the strategy chosen by me for dealing with the challenge is appropriate for my team members to keep learning and gaining knowledge about cyber security in using EMR documentation and accelerate growth in their careers by dealing with such situations. Moreover, authentic leadership focuses on the long-term growth of the organisation (Elrehail et al. 2018). Similarly, the strategy focuses on creating awareness about challenges in EMR that may help in avoiding any kind of patient personal health data breaches in the medical organisation, which would support it for future growth. As an authentic leader, I have active listening skills with the help of which I will hear about the knowledge gap that my co-workers have in ERM. Furthermore, I to get better outcomes in the educating programme and mitigate all the knowledge-based challenges in ERM will also entertain any recommendation if they want to implement this strategy. I will maintain continuity while educating about EMR software that includes patient demographics, lab orders, lab results, medications, and so on to deal with the issue. 

Values of a change agent

The change agent can be referred to as the employee, manager, or external consonant hired for introducing changes in the organisation (Rupietta et al. 2018). Values that are required for being a change agent include active listening skills, diversified knowledge, and flexibility, which I think I possess and can improve more in the future to support my fellow interprofessional and nurses. I will prioritize the changes in the organisation to manage proper documentation and allocate greater services to the patients.

Summary of the issue

It has been found that with the growth of modern technology in the medical industry the paper documentation transformed into electronic documentation, which raises issues like data breaches due to proper taring about using computers, lack of awareness about cyber security issues. Although digital services have made it easier for patients to get great services, they also become the main victim due to internal and external attacks on the electronic documentation of public health. Data breaches and confidential data leakage of the patients have created multiple harms to the patient's life as well as to the healthcare organisation. Besides that, data breaches are related to low-quality services to patients as EMR consists of all the important information that care providers need to check before performing healthcare activities (Seh et al. 2020). Medical professionals being very slow in their typing skills could also be a huge threat to managing patients' data while inputting it in electronic documentation. With the presence of many technologies in today's time, the use of EMR has become vulnerable to hacking, which increases the chance of misuse of patient confidential personal health data. Therefore, it has become a significant issue and change management is required which I have described in the above section.


This report has summarised an accurate strategy that can help in dealing with the challenge in EMR. It has been found that providing continuous training and education to the medical care providers can make them aware of challenges like cybersecurity, which would further help in maintaining patients' records securely. It has also identified that introducing strategy and supporting subordinates to gather knowledge is necessary for managing change in healthcare organisations. 


Seh, A. H., Zarour, M., Alenezi, M., Sarkar, A. K., Agrawal, A., Kumar, R., and Khan, R. A. (2020). Healthcare Data Breaches: Insights and Implications. Healthcare (Basel, Switzerland)8(2), 133.

Tai-Seale, M., Olson, C.W., Li, J., Chan, A.S., Morikawa, C., Durbin, M., Wang, W. and Luft, H.S., 2017. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Affairs36(4), pp.655-662.

Rosario, C., (2019). 4 Problems With Electronic Health Records. Available at: [Accessed on: 1 December, 2021]

Liu ZY, Edye M.ANZ J Surg. 2020 Oct;90(10):1938-1942. doi: 10.1111/ans.15350. Epub 2019 Jul 30.

Alvesson, M. and Einola, K., 2019. Warning for excessive positivity: Authentic leadership and other traps in leadership studies. The Leadership Quarterly30(4), pp.383-395.

Elrehail, H., Emeagwali, O.L., Alsaad, A. and Alzghoul, A., 2018. The impact of transformational and authentic leadership on innovation in higher education: The contingent role of knowledge sharing. Telematics and Informatics35(1), pp.55-67.

Hipaajournal., (2021). Healthcare Data Breach Statistics. Available at: [Accessed on: 1 December, 2021]

Rupietta, C., Meuer, J. and Backes-Gellner, U., 2018. Organizational innovation across the technological innovation process: The moderating influence of hybrid change agents. Universität Zürich, IBW-Institut für Betriebswirtschaftslehre.

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