| > | | | | Patient Privacy |
| When medical practices change over from paper | | | | Do you remember when the HIPAA first |
| to electronic medical records (EMR), steps must | | | | appeared on the scene? No more can you even |
| be taken to ensure that the records remain legally | | | | keep a patient check-in form at the front desk, |
| sound. The change to electronic medical records | | | | or risk having a patient learn who else had been in |
| brings up some issues with compliance, privacy, | | | | on that day. The penalty could include jail time. |
| and security. Below you will find some important | | | | Undue Burden |
| considerations to make when switching your | | | | Some recent legal cases have established that |
| practice over to EMR. | | | | data which is accessible must be able to be |
| When writing and exam on a piece of paper and | | | | produced, including backup data. Although this may |
| signing it, you create a legal document. You are | | | | seem an unfair burden for a medical practice, |
| most likely familiar with the problems that can | | | | experts dealing with these sort of legal cases |
| result from changes to medical records, and the | | | | believe that EMR will result in a decrease of |
| importance of good documentation. The | | | | malpractice suits, as as result of better |
| Healthcare Information and Management Systems | | | | documentation and a lower rate of |
| Society (HIMSS) asserts that electronic medical | | | | medication-related mistakes. Even so, if data is |
| records must be stored legally. Otherwise, these | | | | kept on a failed hard drive, and the costs of |
| records can be challenged as hearsay and | | | | recovering the data is significant, it could create |
| deemed invalid. | | | | an undue burden; judges could rule that the |
| This is important, because when electronic medical | | | | expense be shared between the two parties. |
| records do not meet the legal requirements, a | | | | Accessibility |
| payor can sometimes deny a claim. Also, you | | | | In the world of paper records, charts that are |
| could create the risk of an adverse outcome in | | | | more than seven years old that were purged are |
| litigation. In addition to being sure your electronic | | | | considered legally 'inaccessible.' If a plaintiff's |
| records aren't altered, you must also be able to | | | | attorney asks you to produce the record, it is |
| demonstrate the procedures which are used to | | | | impossible. When it comes to electronic |
| ensure this. | | | | information, however, inaccessibility could be more |
| How, then, can you be sure your electronic | | | | difficult to prove, as electronic data can almost |
| records can't be altered? Ask yourself the | | | | always be recovered. In fact, most of the current |
| following questions: | | | | EMR software systems don't even let a provider |
| Does the system keep a record of who is | | | | delete patient records. |
| accessing and writing to the record? You wouldn't | | | | E-Discovery |
| want your name appearing as the author of | | | | Discovery is the pre-trial phase in a lawsuit. Each |
| another user's entry. | | | | party can compel production of evidence by |
| Does it contain a security protocol which is strict | | | | means of a subpoena or a deposition. E-Discovery |
| but not too time consuming? Features could | | | | refers to information saved in an electronic |
| include an automatic time-out after a period of | | | | format. The collection of digital evidence has even |
| inactivity, and periodic changes to the | | | | spawned the field of cyberforensics. This column |
| alphanumeric passwords. | | | | cannot adequately cover a topic as broad as |
| Does it use a secure 'lock-out' feature? Perhaps | | | | E-Discovery. The bottom line for medical practices |
| the doctors could be able to make changes at the | | | | is that a reliable and secure backup process is a |
| end of the day, but after a certain amount of | | | | must. |
| time has passed the record should lock. | | | | Eventually, rational minds emerged victorious, and |
| Does the system write time stamps on all entries | | | | some of the more inane regulations have relaxed |
| to show an audit trail? For example, the system | | | | a bit. There are still privacy issues which are |
| could write an unalterable draft of each event and | | | | specific to the electronic aspects of medicine, in |
| entry. | | | | regard to inappropriate disclosure of patients' data. |
| By paying attention to these important | | | | An unauthorized email, unsecured wireless |
| considerations, you'll be on your way to ensuring | | | | network, a computer monitor left on in view of |
| your electronic medical records system is legal | | | | another patient are some prime examples. |
| and usable. | | | | |