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Managing the Security of Nursing Data in the Electronic Health Record

Background: The Electronic Health Record (EHR) is a patient care information resource for clinicians and nursing documentation is an essential part of comprehensive patient care. Ensuring privacy and the security of health information is a key component to building the trust required to realize the potential benefits of electronic health information exchange. This study was aimed to manage nursing data security in the EHR and also discover the viewpoints of hospital information system vendors (computer companies) and hospital information technology specialists about nursing data security. Methods: This research is a cross sectional analytic-descriptive study. The study populations were IT experts at the academic hospitals and computer companies of Tehran city in Iran. Data was collected by a self-developed questionnaire whose validity and reliability were confirmed using the experts’ opinions and Cronbach’s alpha coefficient respectively. Data was analyzed through Spss Version 18 and by descriptive and analytic statistics. Results: The findings of the study revealed that user name and password were the most important methods to authenticate the nurses, with mean percent of 95% and 80%, respectively, and also the most significant level of information security protection were assigned to administrative and logical controls. There was no significant difference between opinions of both groups studied about the levels of information security protection and security requirements (p>0.05). Moreover the access to servers by authorized people, periodic security update, and the application of authentication and authorization were defined as the most basic security requirements from the viewpoint of more than 88 percent of recently-mentioned participants. Conclusions: Computer companies as system designers and hospitals information technology specialists as systems users and stakeholders present many important views about security requirements for EHR systems and nursing electronic documentation systems. Prioritizing of these requirements helps policy makers to decide what to do when planning for EHR implementation. Therefore, to make appropriate security decisions and to achieve the expected level of protection of the electronic nursing information, it is suggested to consider the priorities of both groups of experts about security principles and also discuss the issues seem to be different between two groups of participants in the research.


INTRODUCTION
Nursing documentation is an important part of clinical documentation (1). Nurses are the largest professional groups in hospitals and they have a long background in nursing care documentation (2). Nursing documentation is a knowledge source of patient and provable evidence demonstrating how decisions are made and decision outcomes are recorded. In other word, it really highlights what nurse do for patients (3).
Recently, introduction of new technologies has resulted in changes in health care organizations and practices. Documentation is the most important of these changes in transition from a paper-based health record to an electronic health record (EHR) (4). Using modern technologies is unavoidable in the knowledge era, Electronic Health Record (EHR) is the new technology enabling health system evolution (5). The Institute of Medicine's definition of the EHR is a set of components that form the mechanism by which patient records are created, used, stored, and retrieved and located in a health care setting (6). An EHR is used primarily for purposes of planning patient care, documenting the delivery of care and assessing the outcomes of care. In this regard, nursing documentation is an important component of EHR (7). EHR improve the quality of clinical documentation in the medical record (8). Computerized documentation will be the main mode of documentation in the future and is already used in many today's facilities (9).
Use of electronic documentation for nurses becomes relevant because this is where they acquire most of the necessary patient information (10). In this regard, information security is a critical factor for the realization and implementation of electronic health records. EHR security management is very important (11). Security is defined as the protection of system items from accidental or malicious access, use, modification, destruction, or disclosure. As well as, security management is defined as ensuring the confidentiality and privacy through controlling access to intended information (12).
Security in EHR can be seriously threatened by hackers, viruses and worms (13). In today's digital society, concerns about the privacy and security of personal data are constantly increasing, especially in healthcare (14,15).
In addition, there is an increasing need for electronic health information exchange among patients, health care providers and payers, accordingly security and confidentiality of information systems should be considered as important success factors (16). Also, medical staff should be aware of the security measures need to protect their patient data (14). Therefore, many efforts have been made about the security in healthcare information systems in recent years (17). Meanwhile, it was stated that these electronic environments raise new issues of ethics, security and privacy (18). Furthermore, a series of studies suggest that the application of 'health information technology' (HIT) can actually cause security problems (19). The results of Mehraeen's study in Iran indicated that most of the hospitals had addressed issues related to information security in hospital information systems (16).
As well as, Pourasghar's study underlined that the security mechanisms for protecting medical data in HIS environment were inadequate in six university hospital in Tehran (the capital city of IRAN) and all HIS investigated suffered from lack of policies for information security, weak authentication techniques, absence of functions for managing users and log files (20). Therefore, planning and implementing more effective security policies are necessary to overcome weaknesses in different dimensions of information security (16). This study was done to explore opinions of a number of information technology specialists working in the hospital and computer company on nursing data security.

METHODS
This research is a cross sectional analytic-descriptive study in 2013. The study populations were IT experts at Tehran University of Medical Science's hospitals (N=10) and computer companies (N=14) in Iran. These hospitals and companies were accredited and licensed based on the SEPAS standard certificate rendered by the Statistics and Information Technology Office of the Ministry of health & Medical education, and also could represent an array of rich experiences and perspectives about nursing data security. The implementation of Electronic Health Record System (SEPAS in Persian) is the most important strategy of Ministry of Health and Medical Education in Iran. SEPAS acquire information from health care delivery facilities and accumulate. With development of this system, nursing information of individual will be integrated and available everywhere (21). Because, statistical population was limited, the whole population was studied.
Since one hospital was the designer of their hospital information system and also had the SEPAS certificate, therefore, it excluded from the companies, it was considered as hospitals group. Furthermore, three of computer companies did not complete the questionnaires, therefore, the final number of participants was 20. Data was collected by a self-developed questionnaire which was made using the results of a systematic review on security and privacy in electronic health records (13) and expert consensus. This questionnaire had two parts. The first part was related to demographic information of the participants comprising age, gender, academic discipline, educational degree, years in practice. The second part of questionnaire included 71 questions concerning security of nursing data in the electronic health record in three sections including methods of nurses' authentication in EHR documentation (8 questions), levels of information security protection (4 questions) and security requirements (59 questions). Also, an open question was included at the end of the questionnaire. Participants were asked to prioritize each question by a three point scale from "first preference" to "third preference". Each level on the scale was assigned a value starting at 1 (third preference) and ended to 3 (first preference) on the other. Due to high number of questions in security requirements, only the result of questions which were at the first priorities of the both experts, were considered.
The content validity of the questionnaire was confirmed by five specialists (two medical informaticians and three health information management). Cronbach's alpha coefficient was used to evaluate reliability of questionnaire (α≥ 0.71 for all sections). Data analysis was performed by descriptive analytical statistics. To analysis the data, SPSS software version 18 was used.
The Comparison between two expert groups for the nurse authentication in EHR documentation (Table 2), the levels of information security protection (Table 3) and security requirements (Table 4) was calculated by independent-samples t-test (Table 3 and Table 4) and Mann-Whitney's U test (Table  2). Although, the Mann-Whitney Test could not be performed on empty variables of Table 2. A P value of < 0.05 was considered significant. The Kolmogorov-Smirnov Z test was used to determine that the distribution was normal in the groups (P > 0.05). The last question that appeared on the section of security requirements of the questionnaire were openended and allowed for qualitative analysis. Open-ended comments about this final question were reviewed independently by two authors for descriptive reporting of the comments.

RESULTS
The mean age of information technology experts in hospitals and computer companies' experts was 30.2 and 40.4 years respectively. The majority of information technology experts in hospitals (70%) and experts in computer companies (100%) were male. About 50% of information technology experts in hospitals had graduated in associate and bachelor degree, and 40% of experts in computer companies had bachelor degree. The mean of working experiences for information technology experts in hospitals and experts in computer companies were 5.1 and 15.5 year respectively.
As Table 2 shows, the most popular methods for authenticating users in EHR documentation is a user name and password based on experts' viewpoints. According to levels of information security protection (Table 3), administrative and logical controls were also reported as the most important security levels by the experts in both groups.  As well as, the results of security requirements section (Table 4) indicated that some of needs in both groups had high frequency priorities (70% or over), including: Period security update (88.9% , 90%), password management (88.9%, 70%), encrypting confidential information in information transferring process (90%, 70%), the security management of computer networks and sharing of information on these networks (70%, 80%), the applications of secure password system to prevent password cracking or possible attacks (90%, 70%), definition of authorized peoples for deleting documents in organization policies (77.8%, 90%,) data practices policy (77.8%, 70%) the application of authentication and authorization policies (88.9%,90%), access to servers by authorized people (90%, 90%), the hardware and software repair by authorized staffs and contractors (70.0%, 100%), the possibility of backup all electronic documentation and data (77.8%, 100%) based on viewpoint of experts in hospitals and computer companies respectively.
Scores of two expert groups have not significant difference for Tables 3 and 4 (P> 0/05).
In this research, the independent t-test was utilized to compare the mean scores of participating groups. Results indi-cated a non significant difference between the means of two expert group in hospital and computer company on the levels of information security protection (t (12) =.209, p = .838) and security requirements (t 12) = -.058, p = .954).

DISCUSSION
According to the experts' viewpoint of this research, user name and password have the highest priorities among the methods of nurse authentication in EHR documentation. Similarly, in another studies, user name and password were considered as a standard mechanism for limitation of access to important information of patients and also a working electronic signing process in the HIS (20,(22)(23)(24). Although, in today world of technology, the use of biometrics identification techniques including fingerprint, iris scanning, voice and face recognition systems have been increased to identify individuals and control access (25).
Based on Timmerman's model of creating and maintaining document data integrity in an enterprise electronic health record, three levels of security including physical, administrative and logical control are needed in security administration program. Although all the level are important but administrative control can have the most effect in the decrease of the staff errors in data integrity (12). The administrative and logical controls were also emphasized as important levels of information security in present study. Moreover, high point were assigned to the administrative dimension in information security based on viewpoint of more information technology managers of hospital studied in Iran (16).
The more comprehensive functions in EHR needs a more complex access control management model (16). Similarly, it was proved in Timmerman research that access control and audit trials are necessary to be a part of overall security program (12). Although in the present study, the both experts had not the same view about access control in the levels of information security protection. The experts of computer companies believed that access control has most priority, but hospital information technology experts believed that it has least priority among these levels. It is recommended that for final decision, both specialists group take a deep discussion to make best decision considering all aspects of nursing electronic information protection.
California department of public health has prepared information systems security requirements, some of the most important requirements, including conducting the periodic review of system security, establishing a process to review logs for unauthorized access to the system, encrypting confidential information, displaying the warning about unauthorized use of confidential information and providing role based access for authentication (26).From the experts' point of view in this research, the same requirements were also emphasized in security requirements of the nursing documentation in EHR.
Considering security measures to protect unauthorized access to electronic information was stated as main priorities for security requirements by the participant experts of this investigation. Also, according to the study of Harman and et al, implementing security measures sufficient to reduce the risks of impermissible access to electronic protected health information by unauthorized users to a reasonable and appropriate level (14). Moreover, two groups of participants were agreed with items of HIPPA security checklist (27,28). The necessity of having a written policy about all accesses to the health information was emphasized by Farzandipour and et al (29). This research proved that all experts believed as a high priority that some defined policies are needed for legal access to EHR. In addition, according to the study of Park and et al, hospitals can approach information security from feasible security requirements such as policy and regulation making. Also, it is necessary to reflect on the requirements of varied interests such as medical staff, medical consumers and other institutions for information security (30).
In the answer of open questions, two computer companies suggested other security requirements including: data classification based on information security and preventing the unauthorized computer access to the network. Likewise, these important security topics were mentioned in other studies as security requirements and policies (31-34).

CONCLUSION
Due to importance of health information, specially nursing information and the worry of nursing electronic information security, it is recommended to use the expert points of view in designing the national EHR system (SEPAS). In short, the ex-perts had similar views about the levels of information security protection and security requirements regardless of their work place. Therefore, utilizing especially similar views of participants can help in designing the system and prompting nursing electronic documentation. Nursing documentation system contains the patient care information supported with realization of appropriate security requirements. Finally, education and clear guidelines about systems security issues are important to nurses during the implementation of the system.
The knowledge of security should enhance permanently by education, consultation and function of staffs. Also, the establishment of the new field of nursing informatics is recommended to define effective strategy for improving electronic nursing documentation in collaboration with SEPAS stakeholders. This new discipline can manage the nursing information with least security damage according to the progress of information technology.
Acknowledgements Regularly review record of information system activity (such as audit logs, access reports and security incident tracking) 60 90 Periodic review of system security (to ensure the effective operation of management, operations, personnel controls and providing appropriate levels of protection) 75 60 encrypting confidential information in information transferring process base on approved encryption standard 90 70 encrypting confidential information in information storing process base on approved encryption standard 60 60 Policies and procedures to protect electronic health information from any improper change or destruction 50 80 display warning confidentiality of information in all systems containing information 55.6 50 Inactivating account after three failed attempts to log on 44.4 60 Define user roles and types to distinguish between functional and security needs 50 80 the security management of computer networks and sharing of information on these networks Lack of linking computer systems to modems without suitable authority 77.8 55.6 Lack of connection modems to communication networks without authorization 88.9 55.6 Define specific restrictions for third-party access (such as insurance) to system 60 88.9 Define specific restrictions to access a nurse to the system outside the hospital (for example, access to the system from home) 80 66.7 Table 4. The relative frequencies of main priorities of information technology experts in hospitals and computer companies for security requirements