| When a practice makes the switch from paper | | | | records aren't able to be changed? Ideally your |
| records to EMR, some legal concerns will arise. | | | | system will allow users to make changes and |
| Decisions must be made to be sure the digital | | | | correct errors while keeping the integrity of the |
| records maintain legal integrity. There may also be | | | | record intact. |
| some surprises regarding issues of privacy, | | | | * Does your system have a strict security |
| security, and compliance. Here are some things to | | | | protocol which isn't too time-intensive? |
| keep in mind: | | | | Alphanumeric passwords that must be changed |
| Documentation: When you write an exam onto a | | | | periodically? Automatic time-out for inactivity? |
| piece of paper and add your signature, you create | | | | * Does it restrict access to certain features? You |
| a legal document. You probably are aware of the | | | | wouldn't want a front desk employee changing |
| necessity for documentation and the problems | | | | patients' intraocular pressures. |
| which can occur when alterations are made to | | | | * Does it timestamp each entry and show an |
| medical records. Paper charts' integrity are | | | | audit trail? This could be achieved by writing an |
| normally easy to determine. An electronic chart | | | | unalterable record of every entry and event to |
| may be more complicated. The Healthcare | | | | prove the record's validity. |
| Information and Management Systems Society | | | | * Does it use a secure lock-out feature? One |
| says that electronic records need to be stored in | | | | might allow a doctor to make changes at day's |
| a legal manner; otherwise the records can be | | | | end, but after twenty-four hours a record would |
| considered hearsay and legally challenged. | | | | lock. This may seem a harsh measure, but it may |
| What makes this so important? If your electronic | | | | serve you well by protecting you from |
| records do not satisfy the requirements for a | | | | unauthorized changes. |
| legal medical record, a payor can sometimes deny | | | | * Does the system keep track of who |
| claims. Even worse, you could expose your | | | | documented what? You don't want your name |
| practice to increased risks of adverse litigation | | | | associated with another user's entries, or |
| outcomes. Not only do you have to make sure | | | | anonymous changes made. |
| your electronic records aren't altered - you must | | | | If you keep these considerations in mind you'll be |
| also be able to demonstrate your procedure. | | | | able to maintain a proper archive without |
| So how can you be sure your electronic medical | | | | compromising the records' legal authenticity. |